‘Safety starts ... on the ground’ The importance import of ground operations to safety Nov-Dec 2011 Issue 83 ‘Now ssee hear’ Use your radio! ra Be heard, be seen, be safe Check all current charts and documents BEFORE you fly Check all available NOTAMs As a pilot, it is your responsibility to use the correct frequency and use your radio ‘If in doubt, speak out!’ For further information: www.casa.gov.au/nta ISSUE NO. 83, Nov-Dec 2011 DIRECTOR OF AVIATION SAFETY, CASA John McCormick MANAGER, SAFETY PROMOTION Gail Sambidge-Mitchell EDITOR, FLIGHT SAFETY AUSTRALIA Margo Marchbank WRITER, FLIGHT SAFETY AUSTRALIA Robert Wilson SUB-EDITOR, FLIGHT SAFETY AUSTRALIA Joanna Pagan DESIGNER, FLIGHT SAFETY AUSTRALIA Fiona Scheidel ADVERTISING SALES P: 131 757 or E: email@example.com CORRESPONDENCE Flight Safety Australia GPO Box 2005 Canberra ACT 2601 P: 131 757 F: 02 6217 1950 E: firstname.lastname@example.org W: www.casa.gov.au CHANGED YOUR ADDRESS? To change your address online, go to http://casa.gov.au/change For address change enquiries, call CASA on 1300 737 032 DISTRIBUTION Bi-monthly to 90,000 aviation licence holders, cabin crew and industry personnel in Australia and internationally. CONTRIBUTIONS Stories and photos are welcome. Please discuss your ideas with editorial staff before submission. Note that CASA cannot accept responsibility for unsolicited material. All efforts are made to ensure that the correct copyright notice accompanies each published photograph. If you believe any to be in error, please notify us at email@example.com PRINTING IPMG (Independent Print Media Group) NOTICE ON ADVERTISING Advertising appearing in Flight Safety Australia does not imply endorsement by the Civil Aviation Safety Authority. Warning: This educational publication does not replace ERSA, AIP, airworthiness regulatory documents, manufacturers’ advice, or NOTAMs. Operational information in Flight Safety Australia should only be used in conjunction with current operational documents. CONTENTS Features 8 'Safety starts on the ground' The underrated dangers of aircraft ground handling, and how leading operators address them. 20 'The heat is on' Aerial ﬁreﬁghters speak up about the hazards of the job. 24 'Now see hear' Use your radio - and live to ﬂy another day. 28 'Wind farms and monitoring towers' Their potential hazards for aviation. 31 'No-one’s playing consequences' Lessons from a low-key but frightening incident on an international ﬂight are relevant for anyone who maintains an aircraft. 42 'First Part 145' Hawker Paciﬁc Airline Support Services is the ﬁrst organisation in Australia to be approved under Part 145 of the new maintenance regulations. 58 'The ﬁnal piece of the puzzle' The crash of a Vickers Viscount over Botany Bay highlighted the role of technology in creating safe air travel systems. 62 'When it’s time to go' The responsibility of evacuating an aircraft quickly and safely falls squarely on cabin crew. Regulars Information contained herein is subject to change. The views expressed in this publication are those of the authors, and do not necessarily represent the views of the Civil Aviation Safety Authority. 2 Air mail 4 Flight bytes–aviation safety news 16 ATC Notes–news from Airservices Australia 18 Accident reports–International 19 Accident reports–Australian 31 Airworthiness pull-out section © Copyright 2011, Civil Aviation Safety Authority Australia. Copyright for the ATSB and ATC supplements rests with the Australian Transport Safety Bureau and Airservices Australia respectively – these supplements are written, edited and designed independently of CASA. All requests for permission to reproduce any articles should be directed to FSA editorial (see correspondence details above). 34 SDRs 39 Directives Registered–Print Post: 381667-00644. 46 Close Calls ISSN 1325-5002. 46 Programmed to deceive 48 He who rides a tiger 50 Almost pressing the grapes Cover design: Fiona Scheidel Cover picture: © Fraport AG This magazine is printed on paper from sustainably managed forests and controlled sources Average Net Distribution October 2010 - March 2011 87,558 Recognised in Australia through the Australian Forestry Standard 52 66 70 71 ATSB supplement Av Quiz Calendar Quiz answers Flight Safety Australia: winner of the international Flight Safety Foundation’s 2010 Cecil A. Brownlow Award for aviation safety journalism. PA R AV I O N LIA TRA S U A SAFET Y A IR M A IL MARK KROPP WRITES ON ... SHARING THE SKIES SAFELY On Saturday 30 July 2011, I was thermalling a paraglider at around 3,000 feet just south of Beaudesert in SE Queensland. A white and yellow low-wing single seat sports aircraft approached from the south-east and did two complete 360-degree loops around me at around 100m radius and just above my position, before executing a barrel roll and heading off to the north-east. General aviation pilots need to be very aware of what their wake turbulence (wingtip vortices) will do to our aircraft. I was in a thermal in rising air, but the pilot was ﬂying in and out of the thermal and I had no idea where his wake turbulence was going to end up. Paragliders are very susceptible to collapses in turbulent air and this pilot’s foolish antics were putting me at risk. I was too busy controlling my wing to get away from him to have time to reach for my VHF and tell him off. FSA NOV-DEC 2011 2 GA pilots need to be just as aware of what their wake turbulence is doing as they are of how the turbulence from larger aircraft would affect them. Paragliders are highly manoeuvrable, but very slow, and if someone puts us in a bad position we cannot get out of it quickly. It is obviously safer to approach us from downwind and below our position or, better still, just stay right away. GA pilots: we are not ‘toys’ to be played with out in the open sky of class G airspace. “Spidertracks real-time tracking is an extremely important part of our operational and safety mangement. Our pilots and clients rely on spidertracks all over Australia and Papua New Guinea.” Kim Herne - Heliwest Invest in the safety of your crew and family Buy a Spider S3 for only USD995 and pay just USD2 per flying hour To find out more call 1-800-461-776 or go to www.spidertracks.com Several readers expressed concern following last issue's article on with the Lake Eyre broadcast frequency (127.8) procedures, among them: Don M, a private pilot The article concerning the NOTAM about the temporary area broadcast frequency in the Lake Eyre region rang a chord with me because I was one of those who did not read my NOTAMs properly and fell into the trap of broadcasting only on 126.7 as I approached (and landed at) William Creek. It wasn't until I discussed the 'quiet' radio with the proprietor of the local ﬂight charter business that I realised I had been on the wrong frequency. He replied, ‘don’t worry, it happens all the time’. This small change would highlight the names of the affected aerodromes and catch the attention of private pilots, who are often daunted by long NOTAMs full of latitudes and longitudes. MELBOURNE FIR (YMMM) CXXXX/11 REVIEW C1193/11 MARREE, WILLIAM CREEK, LAKE EYRE REGION TEMPO DISCRETE AREA BCST FREQ 127.8 ESTABLISHED IN LAKE EYRE REGION … just a thought. Peter Nicholls 1. Make it a permanent change. What is the problem with having 127.8 promulgated as the permanent frequency for the region? 2. Reword the NOTAM as below (my changes in blue) In your article 'Eyre Space Concerns' I noted in particular the reference to an Airvan on ﬁnal approach into William Creek (WMC) that was 'desperately trying to make contact with an aeroplane which had just entered the runway at WMC’. The aircraft that had just entered the runway is described as the 'offending aircraft', because it backtracked 'without broadcasting on the correct frequency of 127.8’. The frequency of 127.8 has to be used as a consequence of the FIR NOTAM quoted in the article. I suggest that the primary causes of this (chronic) problem are twofold: 1. When NOTAMS for WMC were sought from NAIPS, the response I received, at least up until this week, was 'no current NOTAM'. For that reason alone it is hardly surprising to me that pilots use the CTAF for WMC speciﬁed in ERSA when operating at WMC. The brieﬁng now says, ‘A NOTAM service is not provided’ for WMC. That is one way of reducing the risk of overlooking the required frequency, but it doesn’t seem to me to be the best way. 2. The volume of superﬂuous chaff in brieﬁng material that has to be sorted through to ﬁnd the wheat substantially increases the risk of missing something important. If the correct frequency to be used when operating at WMC is the one speciﬁed by the NOTAM rather than ERSA, the answer is a no-brainer. Surely it is within the capability of mankind and technology to program NAIPS to provide the NOTAM when a location-speciﬁc brieﬁng for WMC (or Marree) is requested through NAIPS, and to leave out of FIR and HO brieﬁngs to civilian VFR aircraft all the irrelevant stuff on ADF FLIP and DAH amendments etc. that constitutes the bulk of the brieﬁngs. 3 AIR MAIL I visited Lake Eyre at Easter and admit to being guilty of the same mistake re the broadcast area frequency. But the fault is not with me, I believe, because the need for you to actually raise this in a magazine article shows there Although I am a relatively low-hours is a root cause procedural issue that pilot, I have accrued my 500 hours unfortunately will not be solved by over a long period and have had a your article. 40+ year career in aviation and ATC, during which I have sometimes been When you have a current copy of the responsible for writing and issuing ERSA it seems illogical to have a longstanding NOTAM which contradicts NOTAMs. it. You even point to a problem in After recovering from the initial the process - the fact that the NOTAM embarrassment of being on the cannot be attached to (for example) incorrect frequency, I naturally looked William Creek because it is an up the NOTAM and was surprised to uncertiﬁed aerodrome. ﬁnd the reference to William Creek buried at the bottom of it, with the The solution is simple – have the main subject appearing to be Lake ERSA reﬂect the current procedures. Eyre. I wasn't going to Lake Eyre that If/when the lake dries up I’m sure it day; I was ﬂying to William Creek, so will be easy to go back to the 126.7 I didn't pay it any particular attention. frequency. Why make life complicated when the solution is so easy? It seems to me that if this problem is ongoing and common, there is a system safety issue here, so it is not just a matter of telling pilots to read their NOTAMs, although that is a good place to start. I have thought about why I missed the alert in my read-through and offer a couple of solutions: And lastly … Clinton McKenzie PA R AV I O N LIA TRA S U A SAFET Y A IR M A IL Mal Wardrop, CASA aviation safety advisor for the central region, responds: FSA NOV-DEC 2011 4 1. The main safety issue identiﬁed back in 2009 was that there were increasing numbers of sightseeing aircraft over Lake Eyre broadcasting on 126.7, rather than on the area frequency. These broadcasts were interfering with other aerodromes with the CTAF 126.7. The ﬁrst draft of the CASA instrument left Marree and William Creek CTAFs on 126.7, with just the broadcast area on 127.8, but consultation with local operators saw the two aerodromes included in the 127.8 area for situational awareness purposes. Airservices creates the NOTAM based on the CASA instrument. There are standard formats for NOTAMs, which by the way are legal documents. 2. Many aerodromes are privately owned and often require prior permission to land (PPR). William Creek is such an aerodrome but it has been my experience that pilots who contact the aerodrome operator for permission usually received additional friendly advice on matters such as parking, fuel availability, and even accommodation. Most importantly, they are briefed on the need to use frequency 127.8 at the aerodrome and over Lake Eyre. This advice is helpful for a safe arrival and an enjoyable stay. VALUABLE SAFETY RESOURCES FROM THE CASA ONLINE STORE 3. Pilots planning to land at unfamiliar aerodromes listed in ERSA should ensure that they make a careful study of all information listed in ERSA. Taking only a cursory glance at the runway direction and length and the CTAF frequency could result in the pilot missing vital information such as Note 1 in the William Creek and Marree entries. Should clariﬁcation of an ERSA entry or a NOTAM be required, the pilot should contact an air services brieﬁng ofﬁcer on the numbers listed in ERSA. Visit www.casa.gov.au/onlinestore to ﬁnd safety information products including posters, DVDs, Z-cards, charts and booklets on topics such as ﬂight planning, helicopter safety, VFR, ageing aircraft, safety behaviours, situational awareness and more. If you have not already explored the joys of the CASA online store now is the time to do so! The Safety Promotion section supports CASA’s mission to create safe skies for all by producing a range of informative resources for aviation professionals and training organisations. The products are all free of charge, but a $15 postage and packing fee applies to each order, whether for one or multiple items, so it makes sense to order more than one item. PRESSURE RELIEF CUSHIONS APPROVED FOR USE Flying can now be more comfortable for passengers who use special cushions to protect them from pressure ulcers/sores. CASA recently approved the use of pressure relief cushions in ﬂight, following a recent complaint from a passenger. David Villiers, manager, Initial Airworthiness section, says CASA was approached by a member of the public complaining about their treatment by a regular public transport (RPT) operator who would not allow the use of a cushion. ‘Cushions are not currently allowed to be used during critical ﬂight phases covering take-off, landing, instrument approach, ﬂight below 1,000ft, and in turbulence, as deﬁned by CAR 251, as this effectively modiﬁes the seat. ‘An inﬂatable cushion is likely to burst during high vertical deceleration and increase loads to the passenger’s spine. QUIZ CORRECTION Thanks to the keenly focused readers who picked up our mistake in September-October’s quiz In question 9 of the SeptemberOctober Flying Ops quiz, the preamble should read ‘with a propeller rotating clockwise from the cockpit’ (as with an American engine), and not anticlockwise (British engine) as written. 5 FLIGHT BYTES ‘We have determined that, other than during take-off and landing, the cushion may be used inﬂated and can also remain inﬂated during turbulence as turbulence encountered by aircraft is never severe enough to activate the energy-absorbing features of aircraft ‘The passenger, who requires a seats. pneumatic pressure relief cushion ‘During take-off and landing the both in their wheelchair and on board cushion must be deﬂated but it the aircraft, asked CASA to clarify does not have to be removed from the use of such cushions on aircraft, the passenger’s seat, as a deﬂated and asked for a written determination cushion is no different from any from CASA to allow its use for future form of loose clothing and in any travel,’ said David. case, the passenger is restrained by the aircraft seat belt. ‘CASA will be making RPT operators aware of this determination.’ KEEPING ON TRACK WITH CASA OnTrack is an interactive guide to operating in and around Australia's controlled airspace. www.casa.gov.au/ontrack The program helps you ﬂy safely by allowing you to preview your ﬂights over unfamiliar terrain before taking to the air. It demystiﬁes Class D procedures and shows you how to avoid airspace infringements. Video, pop-up alerts, location images and animated ﬂight threads take you step by step into and out of Archerﬁeld, Bankstown, Cairns, Cambridge, Camden, Jandakot, Launceston, Moorabbin and Paraﬁeld aerodromes, and speciﬁc location images give you a pilot's eye view of vital tracking and approach points and landmarks. Sunshine Coast, Tindal, Darwin and Alice Springs aerodromes are set to be added during 2012. CASA developed OnTrack with the support of Airservices . DREAMLINER DOWN UNDER FSA NOV-DEC 2011 6 Boeing’s new 787 is going on tour in Australia. The 50 per cent composite-materials-by-weight, new generation airliner will come to Sydney for two days from 15 November, before visiting Melbourne. See the January–February 2012 issue of Flight Safety for an overview of composites in aviation. AND JUST ONE MORE AVIATION HIGH … Noosa District State High School on the Sunshine Coast in Queensland offers Aviation Studies in Years 11 and 12 as an O.P. (university entrance) subject. The school has links with Emerald Free Flying at Caloundra and Pro Sky Flight Training for ﬂying instruction, as well as with Cooloola Flying at Gympie and Becker Helicopters at Sunshine Coast Airport to give students an introduction to control tower operations, ﬁreﬁghting and airport administration. 7 FLIGHT BYTES FSA NOV-DEC 2011 8 and related ground safety are somewhat neglected areas of aviation safety. The Australian Transport Safety Bureau (ATSB) released two reports in 2010: Ground operations occurrences at Australian airports 1998-2008 (report released in June 2010) and Aircraft loading occurrences 2003-2010 (released in December 2010). According to these reports, ‘the aviation industry has been slow to acknowledge the risks associated with ground operations’. There is under- or ambiguous reporting of ground operations issues, some with frightening potential. ‘We can’t underestimate the importance that ground operations have in overall safe operations,’ explains Will Tootell, CASA’s team leader, technical operations. Recognising this, 18 months ago, CASA established a team of ground operations inspectors to oversee ground operations and drive consistency and higher standards. Raquel Moran, based in Sydney, has longstanding experience in airline ground operations and management, across international, domestic, regional and GA operations; David Heilbron, based in Melbourne, joined CASA in 2010, after 12 years ground operations and auditing experience in domestic and international airlines. ‘Since we started the ground operations role towards the end of 2010, we’ve been involved in regulatory service functions which have included the entry into service of aircraft such as a B767 freighter and an A330, aircraft operator certiﬁcate audits, ramp surveillance and special investigations relating to ramp incidents and accidents, load control and aircraft loading, restraint issues and aircraft damage from ramp equipment,’ Moran explained. 9 Consistency, or lack of, in ground operations policies and procedures, is a major issue, according to Joe Hain, one of CASA’s aerodrome inspectors, whose main focus is on aerodrome/airport operators. Hain came to CASA after many years of working with airlines. Ground handling is an extremely competitive business, with conﬂicting pressures from airline schedulers, airport management and autonomous ground handling companies. Add to these the complexity of jurisdiction: are ground operations an aviation safety issue, or an OH&S one? In cases of discrepancies relating to ground operations safety procedures, whose safety management system will take precedence? The airline’s? The airport operator’s? A disturbing example occurred as this issue went to press. As the Sydney Morning Herald reported (20 October 2011), an RPT ﬁrst ofﬁcer was badly injured after he was blown from stairs at the back of a Boeing 737 by the engine thrust from a B747 taxiing close to his plane. Safety experts are looking into how the 747 came close enough to the 737 to blow over the stairs on which the ﬁrst ofﬁcer was standing. The pilot had been conducting preﬂight checks on the parked 737. ‘It’s not so much a case of things falling through the cracks,’ one industry commentator says, ‘as them falling through into a chasm.’ GROUND SAFETY While these reports reveal a relatively low incidence of ground operations issues, and Australia has not experienced a major aircraft accident due to a ground-operations occurrence, some industry insiders say the real ﬁgures are a cause for concern. There is, one writer says, ‘a huge amount of reluctance within the sector when it comes to talking about safety and past incidents’. Regular readers of ground handling trade journals such as the American-based Ramp Equipment and Ground Handling International, would acknowledge that in many aspects of ground handling and ground safety, European operators are leading the way: in technology, in work practices and in training. One such operator, many argue, is Fraport. FSA NOV-DEC 2011 10 Fraport, the German company that operates Frankfurt International Airport, Europe’s third busiest airport after Heathrow (London) and Charles de Gaulle (Paris), as well as having interests in a number of other international airports, also has a very successful ground handling operation. The airport manages 1200 trafﬁc movements a day, and has a reasonably large footprint of 2000 hectares. Bernhard Scholz, Fraport’s executive manager, ground support equipment, is a passionate advocate for efﬁciency and safety in this very busy ground handling environment. The company has an investment of approximately €250 million in ground support equipment (GSE), including de-icing and ﬁreﬁghting equipment. This equates to around 170,000 items, including 1700 motorised GSE units. Fraport is very particular in its selection of ground handling equipment, and operates some of the best in the world, according to Scholz. Their German, Spanish and French equipment is chosen for its efﬁciency and safety, with Goldhofer pushback tractors just one example. The Goldfhofer is towbarless, making for safer, more efﬁcient operations, Scholz says. Due to the large number of aircraft types, and the size of today’s airports, logistics require faster and more ﬂexible aircraft ground handling, to make better use of the existing infrastructure. Environmentally conscious towing, with a corresponding reduction in jet fuel consumption, is also becoming more important. The towbarless tractor’s faster driving speed allows up to three times faster pushback than operations using conventional towbar tractors, and, its users argue, is much safer. in a pushback operation has led to a number of ramp accidents. In one case, for example, quoted in the August 2011 issue of Ground Handling International, the use of a poorly-marked towbar, 55cm shorter than the correct towbar for the pushback of a Fokker 100 led to a 300mm indentation in the nose cone of the aircraft. The pick-up device is the heart of all such towbarless tractors. During towing, sensors continuously monitor and control the pick-up device, immediately displaying any malfunctions to the driver.The suspension of the pick-up device also ensures that it can accommodate the movement of the nose-gear, without inducing additional forces during cornering. The more controlled, one-person, cab-based operation of the towbarless tractor, it is argued, is safer than conventional towbar operations, reducing the risk of damage to humans and aircraft. The physical action and coordination required by the operator to move an aircraft with a towbarless GROUND SAFETY Towbarless tractors, as the name suggests, do not use a towbar. On the towbarless tractor, the nosegear tyre is in the pick-up device, which is located in the centre of the vehicle. This pick-up device draws the aircraft onto a platform and lifts it. There is a direct and ﬁrm connection between aircraft and tractor, so the combination can be moved without problems at speeds of up to 30km/h. One person can control the pick-up and release of aircraft, carrying out all movements from the cab, so a ‘brakeman’ is no longer necessary. On the other hand, conventional towbar tractors need to have a gross weight of approximately 70 tonnes so they can transmit the tractive force required for large aircraft, for example, a Boeing 747. Conventional towbar towing permits a maximum towing speed of 15km/h because of the driving dynamics. The shear pins on the tow bar avoid excessive tractive and braking forces being induced in the aircraft. That is why a ‘brakeman’ must always be in the cockpit to stop the aircraft safely if a shear pin breaks away. The main advantage of a towbarless tug is simplicity. If you eliminate the towbar altogether, you eliminate the need to have a variety of aircraft type-speciﬁc towbars. Confusion about the correct towbar to use 11 tractor is simpler and easier to learn than one with a towbar. By connecting the tractor directly to the aircraft's landing gear—instead of through a towbar—operators have better control and responsiveness when manoeuvring. Not only that, but many towbarless tractors have ergonomically designed cabins, with seats that can be rotated 180°, giving the driver the best possible visibility, and with suspension designed to minimise spinal shock. However, Flight Safety Australia understands the situation in Australia is still much the same as in 2004, when Australian safety expert, Geoff Dell, reported: ‘The penetration of towbarless tractors into the market has been limited … The industry culture in many parts of the world continues to support the notion that a licensed maintenance technician must be available to react to emergencies during pushback and engine start, despite there being no hard evidence.’ Fraport encourage ongoing innovation, and have won various awards recognising this. Modiﬁcations made to their ladder operations, for example, won them the 2003 Ground Handling International Ramp Safety award. FSA NOV-DEC 2011 12 Fraport have also introduced GPS tracking for their GSE. This monitors the location, status and use of the equipment, allowing comprehensive management of the GSE ﬂeet, including features such as geo-fencing, access control, engine operation, general vehicle status, service registration and maintenanceplanning information. A software module displays all GSE units on the system’s airport map, showing their current location and operational status. The GSE units are equipped with on-board units powered by the GSE’s on-board electric system and can be linked to other on-board systems. Each onboard unit connects to the central server via GPRS or Wi-Fi. The GSE historical operational data and all other relevant information is saved and is used to evaluate usage, operating times and distances travelled, as well as to support efﬁcient GSE maintenance plans. To increase operational efﬁciency, the condition of certain types of GSE can be controlled; the system monitors and issues warnings about low fuel, high oil temperature, low battery level or (for example in the case of high loaders) engine running without lift operation during a certain period of time. If a low-fuel warning is generated and forwarded in real time, the system can automatically generate a fuelling task. The system also facilitates increased safety and security on the apron. The geo-fencing function means speciﬁc areas can be deﬁned as prohibited, so that warnings are given when speciﬁc GSE units, or GSE in general, enter this prohibited area, or leave their allocated areas. Geo-fences can be permanently ﬁxed areas, or set for a limited time (e.g. on construction sites). The on-board units can also register movements and impacts during engine-off times, as well as controlling vehicle speed and issuing alerts if speed limits are exceeded. Each vehicle can be registered to its assigned operator, to prevent unauthorised use, or to allow further control of its operation. Airport operators are aware of the twin safety issues of congestion and excessive GSE speed; the GPS tracking and controlling capability provides an alternative to instituting speed limits, with their accompanying surveillance requirement. ‘Maintenance is a ground safety issue’, Scholz explains, and all the GSE are on an ongoing annual maintenance schedule. ‘It’s all computer-based’, he says, ‘so we have an overview of every screw, and can see that everything is operable, and which GSE is due for maintenance.’ This computerised system is backed by old technology: the hubs of serviceable GSE are painted bright pink, so that they can be readily identiﬁed on the apron. But above all, Scholz argues, ‘education is still the most important part of safety’. Some operators, trying to cut costs, hire people with no education, and if these people don’t think, then you have a problem. ‘It is becoming harder and harder,’ he says, ‘because from an airline point of view, ground handling is too expensive, so there are downward pressures on costs.’ However, Fraport’s ﬁfty-per-cent German-born, and ﬁfty-per-cent immigrant workforce is ground handling certiﬁed by the German government. Fraport is strong on training, and has a tiered driver education program. Level one drivers are qualiﬁed to operate conveyor belts and small tractors; level two includes equipment such as steps; and level three is the highest equipment level. Ground handlers wanting to become drivers have to complete an accident-free year to qualify for level one. If they do have an accident, they go back to loading in the belly. Likewise, there is also a tribunal which adjudicates on accidents. The evidence in the accident report is examined, and the employee concerned is interviewed. Employees are offered ‘goodies’ - incentives such as improved conditions, and medical beneﬁts, which help to ensure that the Fraport ground-handling workforce, unlike many, is relatively stable. This workforce retention then has an impact on the effectiveness of the training program. One group promoting ground safety in Australia and New Zealand is the Australasian Aviation Ground Safety Council (AAGSC), comprising members from major Australasian airports, ground handling companies and airlines. As part of promoting ground safety, the AAGSC sponsors an annual ground safety award. One of this year’s entrants is Virgin Tech’s aircraft towing simulator, which the company developed in response to several identiﬁed training issues. Engineers and some contractors are required to tow aircraft as part of their regular work tasks. Towing occurs at airport terminals during the departure of aircraft, aircraft relocations, and when transferring aircraft to and from maintenance facilities. 13 GROUND SAFETY If a deliberate ﬂouting of the rules caused the accident, the tribunal, comprising union, management and safety management members, meets to determine the penalty or punishment. This could be the ramp worker losing their ramp driving licence for six months or a year; losing their privileges; or going back to training school. Learning how to tow aircraft safely, and assessing competence in doing this, have usually been achieved either by towing freight barrows or other GSE, or through on-the-job training using actual aircraft. However, Virgin Tech felt this was not ideal. Tow training on freight barrows and other GSE was very unrealistic, and using an aircraft, while providing real skills to the trainee, brought signiﬁcant disadvantage and risk. Spare aircraft for such training can be difﬁcult to ﬁnd, and if available, are often only available at night, when routine workload is high and visibility reduced. There is also the risk of damage to the aircraft during the training session. And ﬁnally, most available areas for training with aircraft are very hazardous: the congestion and noise of normal airport operations coinciding with the training session. FSA NOV-DEC 2011 14 So Lachlan French, Virgin Tech’s Melbourne-based training manager, decided that a towing simulator would be the most appropriate solution to minimise both the risk and the interruption of day-to-day airport operations. The company considered a computer-based simulator, but felt this would not offer the desired real-world experience of a handson towing simulator. Working with the Virgin Tech GSE leader, French developed the towing simulator, enabling trainees to become competent in a safe and controlled environment. The towing simulator is scaled to the dimensions of a Boeing 737-800 aircraft, to best simulate the performance, feel and responses of actually towing an aircraft. The towing simulator has the following features: The towbar connection point is a dual wheel turntable ﬁtted with audible and visual warning indicators to alert the trainee when the maximum aircraft turning angle has been reached. It can be attached to a tug or other suitable towing vehicle using a conventional aircraft towbar. A vertical stabiliser adds realism, and more importantly, is an indicator for marshalling and spatial referencing. As well as being scaled to a Boeing 737-800 the wheel base and track are designed to the same ratio as a B737. The simulator frame can shortened by relocating two bolts, so that it is easier to transport and store. The battery powering the maximum turn angle warning indicators is recharged using an on-board 240V charger. This charger can be substituted with a solar charger if the simulator is stored out of doors. A 1000-litre ballast tank is ﬁtted to adjust the axle weight of the simulator as required. Following the success of the ﬁrst towing simulator, the company is manufacturing a second for use in their Brisbane hanger. To ensure a thorough understanding of the operation of the towing simulator, French and Virgin Tech training developer, Peter Hancock, developed a comprehensive training and assessment package, in three parts: 1. the operation of the various towing tractors and tugs in the Virgin Australia business. 2. guidance material and exercises for the students to use with the towing simulator. (The longest part of the course). Potential trainees must have a number of licences: a valid state or territory driver’s licence, a valid airside driver’s authority, and a radiotelephony licence. As this issue of Flight Safety Australia went to print, submissions for the award were being judged. Results will be published in the January-February 2012 issue of the magazine. Thanks to the AAGSC and Virgin Tech for permission to use this material. GROUND SAFETY 3. involves combining all the acquired experience by performing tows on aircraft under the direct supervision of an experienced, approved aircraft tower. Only after successfully performing a number of tows, under a variety of conditions, would the student be assessed for competence. 15 ATC notes Operations at non-conforming cruising levels Conforming (often referred to as standard) cruising levels provide a layer of safety in all airspace classifications. Deviation from conforming levels erodes a key system defence, which is why exposure to the increase in risk should be kept to a minimum. FSA NOV-DEC 2011 16 0° EVEN Thousands to FL 280 then FL 300 FL 320 FL 340 FL 360 FL 380 FL 400 359° FL 430 etc 180° ODD 179° Thousands to FL 290 then FL 310 FL 330 FL 350 FL 370 FL 390 FL 410 FL 450 etc 0° EVEN Thousands PLUS 500 to FL 185 ODD 179° Thousands PLUS 500 to FL 195 VFR FLIGHT NOT PERMITTED IN CLASS A AIRSPACE The latest change places the onus on the pilot to only request a non-conforming level when 359° 180° IFR CRUISING LEVELS airways system while keeping risk levels as low as reasonably practicable. VFR CRUISING LEVELS Source: AIP ENR 1.7 – 10, n recent years there have been numerous discussions between Airservices, airlines, pilots, and CASA regarding pilot requests to operate at non-conforming levels. I There have also been multiple incidents in which non-conforming levels have been found to be a contributory factor. As a result, both AIP have amended procedures surrounding nonconforming levels. (AIP ENR 1.7-6). The pilot must include the phrase “due operational requirement” when requesting a non-conforming level. ATC will then assess a non-conforming level request. A controller can assign a non-conforming level require, but is required to continually assess the suitability of this arrangement and return the aircraft to conforming levels as soon DV¬SUDFWLFDEOH As a pilot, when operating at a non-conforming level, you should advise ATC as soon as the operational requirement ceases and you are able to return to a conforming level. You can now get the latest Airservices news and updates via our Twitter account: @AirservicesNews We will use Twitter to keep you informed about a range of Airservices activities, including news, updates to our website, the release of new documents and publications, new safety promotion products, and our attendance at events. ICAO 2012 flight plan changes how will this affect you? Many pilots are already aware ICAO has issued Amendment 1 to the PANS-ATM 4444 provisions for flight planning, involving changes to content and indicators used in the ICAO flight plan form. Global implementation is planned to commence from mid-2012. T "JSTFSWJDFTJTNBLJOHDIBOHFTUPJUTnJHIU QMBONFTTBHFIBOEMJOHTZTUFNTBOEBJSUSBGmD control displays to ensure a smooth transition. 4ZTUFNNPEJmDBUJPOTXJMMJODMVEFUIF/"*14 nJHIUQMBOOJOHJOUFSGBDF5IFHFOFSBMBWJBUJPO DPNNVOJUZDBOFYQFDUTPNFDIBOHFTUPnJHIU planning requirements as a result. While there will be less impact on most general BWJBUJPOPQFSBUPSTUIFDIBOHFTQSJNBSJMZSFMBUFE UPOPUJmDBUJPOPGBEWBODFETVSWFJMMBODFBOE OBWJHBUJPODBQBCJMJUJFTTVDIBT1#/FRVJQBHF will still need to be universally understood. As we move closer to transition, further information will be provided in this magazine, AIP Supplements, the Airservices website and direct mail to pilots. More information: The main changes are: OFXBMQIBOVNFSJDDPEFTGPSOPUJmDBUJPO of advanced radio communication and approach aid equipment/capability in item BPGUIFnJHIUQMBO Airservices: www.airservicesaustralia.com AIC H08/11 – https://www. airservicesaustralia.com/publications/current/ sup/a11-h08.pdf ICAO PANS-ATM Doc 4444, 15th Edition – Amendment 1 http://www2.icao.int/en/FITS/ FITSLibrary/PANS%20ATM%20Amendment. pdf NJOPSDIBOHFTUPTFWFSBMFYJTUJOHDPEFTJO item 10a OFXDPEFTGPSOPUJmDBUJPOPGTVSWFJMMBODF equipment in item 10b including ADS-B and ADS-C $VLD3DFLÀF5HJLRQDO*XLGDQFH http://www. bangkok.icao.int/edocs/FPL_Guidance_ver3. pdf TFWFSBMOFXJOEJDBUPSTJOJUFNPGUIFnJHIU plan including PBN ,&$2,PSOHPHQWDWLRQ http://www2.icao.int/ FO'*541BHFTIPNFBTQY strict rules for content allowed in STS/ indicator in item 18. 17 ATC NOTES he change is being made to meet the needs of aircraft with advanced navigation and communication capabilities. It will also enable ongoing moves towards automated air USBGmDNBOBHFNFOU"5. TZTUFNT5IFDIBOHFT XJMMIBWFBTJHOJmDBOUFGGFDUPO"JSTFSWJDFT"5. systems and on major RPT operators. International Accidents/Incidents 8 August 2011 - 29 September 2011 FSA NOV-DEC 2011 18 Date Aircraft Location Fatalities Damage 8 Aug Antonov 24RV Blagoveshchensk Airport, 0 Russia Written off Passenger plane (ﬁrst ﬂight 1976) substantially damaged in a runway excursion on an en route stop at Blagoveshchensk Airport. All 36 occupants survived. 9 Aug Antonov 12A Omsukchan, Russia 11 Written off Cargo plane (ﬁrst ﬂight 1963 - the oldest plane of the Russian commercial airﬂeet) crashed about 10km from Omsukchan after the crew reported a fuel leak and an engine ﬁre. No survivors. 15 Aug Lockheed C-130 Hercules over Afghanistan 0 Minor Lockheed Hercules damaged in a mid-air collision with a 170kg AAI RQ-7 Shadow unmanned aircraft over Afghanistan. The Shadow UAV struck the Hercules' left wing and crashed, but the Hercules managed to land safely. 20 Aug Boeing 737-210C near Resolute Bay Airport, Canada 12 Destroyed Passenger plane (ﬁrst ﬂight 1975), with 11 passengers and four crew members on board, destroyed when it ﬂew into terrain while on approach to Resolute Bay Airport. Weather reported as a 200ft ceiling with three miles visibility in fog and drizzle. Wind 180 degrees at 10kt. 21 Aug BAE Hawk 1.6km from Bournemouth 1 Airport, UK Destroyed Red Arrows pilot killed when his aircraft crashed into a river embankment after a ﬂying display at Bournemouth's annual air festival. 28 Aug Antonov 2R near Neschadinovskay, 1 Krasnodar region, Russia Destroyed The Antonov with two occupants, operating on an illegal crop spraying ﬂight, crashed and burst into ﬂames during an emergency landing. 2 Sept Cessna 208B Grand Caravan and Cessna T207A Turbo Stationair 7 14km north of Nightmute, 1 Alaska, USA Destroyed Two planes being operated under VFR collided in mid-air. The 208B crashed, killing the pilot, and the 207 made a forced landing, which the pilot survived. The two pilots had a close personal relationship and had been talking on a discrete radio frequency and ﬂying their planes very close together before the impact. 2 Sept CASA C-212 Aviocar off Isla Robinsón Crusoe Airport, Chile 21 Destroyed Chilean Air Force transport plane (ﬁrst ﬂight 1994) destroyed when it crashed into the sea on approach to the airport, killing all aboard. The passengers included a crew from Televisión Nacional de Chile and NGO and Air Force personnel en route to see the progress of relief activities after the 2010 earthquake. 6 Sept Swearingen SA.227BC Metro III 8km NW of Trinidad Airport, Bolivia 8 Destroyed Passenger plane (ﬁrst ﬂight 1992) crashed into jungle while on approach to runway 14, killing the two crew and six of seven passengers. The wreckage and the sole survivor were not found until 8 September. 7 Sept Yakovlev 42D 2km from YaroslavlTunosha Airport, Russia 44 Destroyed Passenger plane (ﬁrst ﬂight 1993) crashed into the Volga River during initial climb. On it were members of the Lokomotiv Yaroslavl ice hockey team. It was reported that all the engines were working until the aircraft ran off the runway onto grass, barely climbed and then collided with obstacles. The stabiliser was set to 8.7 degrees nose up and the ﬂaps were at 20 degrees before take-off. 9 Sept Cessna 208B Grand Caravan 1 near Tangma, Yahukimo District, Indonesia 2 Written off Aircraft carrying four drums of diesel fuel and some goods to a remote airstrip crashed in mountainous terrain. 14 Sept Embraer 120ER Brasilia Huambo Airport, Angola 26 or 30 Written off An Angolan Air Force aircraft crashed on take-off, broke in two and caught ﬁre. Conﬂicting media reports say that 26 or 30 occupants, including three army generals, were killed. Six occupants survived. 16 Sept P-51 Mustang Reno, Nevada, USA 11 Destroyed The P-51 ﬁghter, taking part in the National Championship Air Races, suddenly pitched upwards, rolled, and nose-dived into a section of seats, killing the pilot and ten spectators and injuring at least 69 more. Witnesses said that the trim tab appeared to fall off the tail. 20 Sept Pitts Model 12 Wheeler Downtown Airport, Kansas, USA 1 Destroyed The custom-built biplane nose-dived into the ground adjacent to one of the runways and burst into ﬂames, after failing to pull up from a downward spiral during aerobatic manouevres. 20 Sept Beechcraft 99A near Milot, Haiti 3 Destroyed Passenger aircraft (ﬁrst ﬂight 1969) crashed in a ﬂooded sugar cane ﬁeld in poor weather with heavy rain. 22 Sept DHC-6 Twin Otter 300 Yellowknife, Northwest Territories, Canada 2 Written off Float plane (ﬁrst ﬂight 1973) sustained substantial damage when it crashed in a street next to Yellowknife Waterdome, killing both pilots. 23 Sept DHC-3T Texas Turbine Otter near Heitman Lake, Alaska, USA 1 Written off Aircraft crashed on approach to Kodiak Airport. The pilot was killed and the two passengers seriously injured. 25 Sept Beechcraft 1900D 8km SSE of Kathmandu- 19 Tribhuvan Airport, Nepal Written off The Beech 1900 (ﬁrst ﬂight 1997) was on the base leg of the approach following a sightseeing ﬂight when it crashed into the roof of a house in a village about 3nm short of the runway threshold in rain and dense fog. 29 Sept CASA/Nurtanio NC212 Aviocar 200 near Bohorok, Sumatra Written off Aircraft (ﬁrst ﬂight 1989) crashed in a forest. Rescuers unable to reach the site until 1 October because of poor visibility. No survivors. 18 Description Notes: compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/) and reproduced with permission. While every effort is made to ensure accuracy, neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on preliminary reports only. For further information refer to final reports of the relevant official aircraft accident investigation organisation. Information on injuries is not always available. Australian Accidents/Incidents 4 August 2011 - 29 September 2011 Date Aircraft Cessna 172B Location Injuries Kondinin (ALA), WA Nil Damage Serious 15 Aug Cessna 177 Cardinal South Grafton (ALA), NSW Nil Serious 15 Aug Piper PA-28-180 Archer Horsham Aerodrome, N M 40km, Vic Cessna 210N Kununurra Centurion Aerodrome, WA Aerospatiale Marree (ALA), N M AS.355F2 Squirrel 145m, SA Auster J5B Broken Hill Aerodrome, 359° M 17km, NSW Cessna U206G William Creek (ALA), 040° M 117km (Lake Eyre), SA Air Tractor Pearce Aerodrome, AT-802 002° M 74km, WA Boeing 737-8FE Christchurch International, NZ RolladenKingaroy Schneider Aerodrome, Qld Flugzeugbau LS8-18 Robinson R44 II Plutonic Gold Mine Aerodrome, 322° M 63km, WA Aerospatiale Rockhampton AS.350BA Aerodrome, 341° M Squirrel 98km, Qld Fatal Destroyed Minor Serious Fatal Serious Nil Serious Nil Serious Nil Serious Nil Serious Nil Serious Fatal Serious It was reported that the helicopter collided with terrain. The investigation is continuing. Fatal Serious 11 Sept Air Tractor AT802A Nil Serious 12 Sept Robinson R44 Emerald Aerodrome, 097° M 37Km, Qld McArthur River Mine Aerodrome, 228° M 45km, NT Nil Serious 26 Sept Cessna 152 near Bankstown Aerodrome, NSW Nil Serious 29 Sept Robinson R22 Beta Maningrida Aerodrome, 189° M 62km, NT Nil Serious A passenger reported that the helicopter crashed while on communications tower maintenance ops. The police advised two of the three people on board were dead and one was injured. The investigation is continuing. During take-off, the aircraft struck an Australian bustard. The impact damaged the wing, causing a loss of control, and resulted in the left wing striking a fence. During cruise, the engine ﬁre light illuminated and the oil pressure dropped to zero. The pilot conducted a precautionary landing and noticed ﬂames emanating from the engine after landing. The subsequent ﬁre caused serious damage. The investigation is continuing. During initial climb, the aircraft's engine failed and the crew conducted a forced landing in a paddock. The aircraft ﬂipped over and came to rest inverted. The investigation is continuing. During aerial mustering, the helicopter's tail rotor collided with a tree and the helicopter landed heavily. The investigation is continuing. 04 Aug 18 Aug 18 Aug 21 Aug 23 Aug 26 Aug 01 Sept 02 Sept 08 Sept On approach to the aerodrome the aircraft landed short of the runway and was damaged. The investigation is continuing. The helicopter collided with terrain. The pilot and two passengers were fatally injured. The investigation is continuing. During landing ﬂare, the aircraft drifted off the runway centreline, and the pilot applied power for a go-around. The aircraft stalled and the main landing gear collapsed. During a scenic ﬂight, the engine lost power. The pilot and ﬁve passengers were not injured in the resulting forced landing. The investigation is continuing. During aerial spraying, the aircraft struck a powerline, and then the ground. The investigation is continuing. While taxiing for take-off, the aircraft's wing tip collided with the horizontal stabiliser of a parked aircraft. Before touch down, the left wing contacted the glider strip markings, resulting in the aircraft striking the ground. Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result of a cooperative effort between the ATSB and the Australian aviation industry. Data quality and consistency depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting from the use of these data. Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents. 19 ACCIDENTS/INCIDENTS 03 Sept Description During landing roll, the aircraft was affected by a wind gust. The pilot could not maintain directional control and the aircraft veered off the runway and came to rest in low scrub. On the base leg of the circuit, the aircraft's engine failed and the pilot conducted a forced landing. The aircraft landed short of the runway and collided with a drainage channel. The investigation is continuing. The aircraft collided with terrain. The three occupants were fatally injured. The investigation is continuing FSA NOV-DEC 2011 20 JRM-3 Martin Mars tanker ﬂanked by an S-76. Photo courtesy of Coulson Flying Tankers, British Columbia As another bushﬁre season approaches, so does the question of how to safely ﬁght ﬁres from the air. Training, fatigue, and the issue of who should have responsibility for managing these issues are the questions aerial ﬁreﬁghters and state bushﬁre agencies are wrestling with. Some are now calling for the role of ﬁreﬁghting pilot to be recognised with formal training and qualiﬁcations. Finding the right pilot, with the best combination of experience, attitude and skill is a challenge in any ﬂying operation but, particularly so in aerial ﬁreﬁghting, John McDermott, chief pilot of McDermott Aviation, told this year’s Australian Aerial Fireﬁghting Conference in Melbourne. ‘Aviation skills are certainly not reﬂected by hours. Skills and attitude are hard to come by in combination, especially as a ready-made ﬁrebombing pilot,’ he said. Even experienced agricultural pilots can ﬁnd the transition to the smoke and turbulence-ﬁlled intensity of ﬁreﬁghting operations a challenge. ‘You might have a pilot whose career has been spraying cotton on ﬂat land. They’re experts at it, but if you put them in the hills, with a heavy load, it’s a totally different game,’ McDermott said. Maryanne Carmichael, NSW Rural Fire Service (NSW RFS) manager of aviation, said: ‘Collectively, we’ve got a challenge in how we maintain our pilot numbers and get new pilots through.’ Barry Foster, chief pilot of Woorayl Air Services told the conference, ‘I really think we need a rating. If it goes through the (state ﬁreﬁghting) agencies there will be all sorts of different competencies wanted. We need one federal rating.’ McDermott said: ‘I think the way to do it for the agencies is to have an approved training process that leads to a certain standard.’ ‘If we had an aerial ﬁreﬁghting rating, similar to an agricultural rating, it would be a big step in agencies feeling comfortable about what standard of pilots they were getting.’ ‘We also know we’re not going to keep all the pilots ourselves – some of them will go back into the pilot pool, but we accept that, because we hire some pilots from the pool as well.’ McDermott said he believed in taking less-experienced pilots and nursing them through. ‘During that process you can also develop the right attitude: ‘doing the job in a professional way and going home every night”. ‘With a rating, it would be feasible to put newly rated pilots on grassﬁres for their ﬁrst 100 hours of ﬁreﬁghting. That could be a means of progressing people. For helicopters, command and supervision works well, but that depends on the type you’re ﬂying. And that’s something agencies might have to accept – that (Bell) 212s might have to reduce their load by the weight of a supervising pilot.’ 21 THE HEAT IS ON ‘In the old days there used to be ﬁxed-wing top dressing in the hills, but that’s all gone now. You can get pilots with 10,000 hours experience, all low level, all precision, but ﬂying up a deadend valley in a heavy aeroplane is new to them. There’s a whole different set of skills, that, to be honest, you don’t get in straight and level ﬂying in open country.’ For now, the burden of training and of setting ﬂying standards falls on aerial ﬁreﬁghting contractors themselves. According to Foster, ‘we offer full-time employment and we put a lot of training into our employees. Photo courtesy of Coulson Flying Tankers ‘One of the major issues we saw in the 2008-09 season was pilot fatigue,’ NSW Rural Fire Service superintendent, Keith MacKay, told the conference. Part of the challenge in managing fatigue, Mackay said was the long list of organisations and regulations claiming jurisdiction over the ﬁreﬁghting workplace. These include the RFS Act and Regulations 1997, WorkCover, the Environmental Protection Authority, the Dangerous Goods Act, International Civil Aviation Organization (ICAO) regulations, the Civil Aviation Act and Regulations 1988, and Airservices Australia, which manages airspace. Fatigue was covered by CAO 48 and CASR Part 137, as well as by the fatigue management system adhered to by individual operators. NSW RFS 2009–2010 seasonal overview The result was confusion, Mackay argued, with pilots covered by one set of regulations being allowed to ﬂy for 14 hours a day, and others restricted to 12 or 10 hours of duty. At the other end of the scale, in many cases there was failure to address the RFS requirements. ‘In some cases there are also failures to address legislative requirements,’ he told the conference. Mackay made the point that ﬁreﬁghters were not aviators by background or training. ‘We’re not aircraft operators, yet we’re being asked to be more and more involved in monitoring that industry,’ Mackay said. ‘There’s a huge variation across the country in standards and practices in occupational health and safety.’ ‘We saw it come through on paperwork we were receiving that some pilots were doing work for two companies, and not really being monitored correctly.’ ‘We have to break down all these processes into a common message - that we’re managing fatigue.’ FSA NOV-DEC 2011 22 Documentation and consistent procedures were the foundation of safety, Ogden, a former naval ofﬁcer, helicopter pilot and safety specialist, said. ‘We live in a systems world. You can’t deny that. Get used to it, or the reality is you will likely be out of business.’ Mackay proposed that legislation be harmonised, or replaced, for ﬁreﬁghting: Operators who had adopted the systems approach and were using it to continually improve their operations were also enjoying the beneﬁts of contracts with mining, oil and gas companies, he said. ‘That is, that we as ﬁreﬁghters are only allowed to work 12 hours in a shift. By adopting this, all RFS personnel would automatically understand how to manage pilots and their fatigue.’ ‘I see this in much of the oil and gas business and the minerals business. If you’re not capable of operating to their standards, it really is a case of don’t bother tendering as they’re not interested.’ Mark Ogden, aviation consultant to the NSW Rural Fire Service, said there was a large variation in standards among aerial ﬁreﬁghters. ‘The variation between operators is immense. The larger operators are systems-based and their documentation is good,’ he said. The NSW RFS has developed a series of risk-based standards, making its requirements clear to aerial ﬁreﬁghting operators. These allow an operator to provide an alternative means of compliance. Ogden said the winch standard drawn up in 2008, and revised in 2010, had found general acceptance in the aerial ﬁreﬁghting industry. A draft fuel supply standard will be available for industry comment soon, while bombing and observation standards are planned. WHY PURCHASE THE R66 TURBINE FROM HELIFLITE: ;(2,(+=(5;(.,6-/,30-30;,»:,(93@:36;: -(*;!*<99,5;9796+<*;0653,(+;04,1(5<(9@ -(*;!*<99,5;/,30-30;,9:36;3,(+;04,,(93@ 46:;,?7,90,5*,++0:;90)<;69:05*, 7 -<33(<:;9(3(:0(55,;>692*6=,9(., 3(9.,:;05=,5;69@6-96)05:65/,30*67;,9: 3(9.,:;05=,5;69@6-96)05:65:7(9,7(9;: 3(9.,:;46:;,?7,90,5*,+:,9=0*,:<7769;;,(4 (<;/690:,+9633:96@*,99:,9=0*,*,5;9, Ph: 02 9766 0200 ^^^OLSPÅP[LJVTH\ 9VIPUZVU:HSLZ (N\Z[H>LZ[SHUK:HSLZ 23 None of these technologies is new: Los Angeles County Fire Department ﬁrst used night vision goggles in helicopters in 1974; thermal-imaging cameras have been around since the 1990s; and military laser targeting systems for aircraft were developed in 1981. But using them in combination is producing a new, safe and effective way to ﬁght ﬁres, operators involved in the trial say. Veteran US aerial ﬁreﬁghter Dennis Hulbert described the system to the Australian Aerial Fireﬁghting Conference in Melbourne this year. A controller at altitude in a Sikorsky S-76 uses a forwardlooking infrared (FLIR) to discover hotspots that might be hidden from the naked eye by smoke. The controller in the S-76 uses a gimbal-mounted laser designator, guiding an S-61 ﬁreﬁghting helicopter to the best place to drop its ﬁre retardant. The S-61 pilot is able to see the laser dot, which shows up brightly in third-generation night vision goggles. There is no longer the ambiguity that comes with verbal descriptions of the drop point over the radio network. ‘In southern California you’ve got about 30 aircraft on a ﬁre: your rotary-wings down low, your tanker orbit and your tanker drops,’ he said. ‘There’s a lot of communication and many missed opportunities for drops … you may drop somewhere that’s less efﬁcient simply because there’s no other opportunity. At night you don’t have to worry about that because there are fewer aircraft. It creates an easier environment to work in. There’s also less wind, less of a smoke column at night. ‘You get better efﬁciency: instead of collecting from your water source, going into an orbit, and waiting, you’re able to ﬂy straight to your drop point. ‘You’re able to transit direct to the ﬁre - you’ve got a sterile radio environment because the target description is done by the laser. The pilots know exactly where to go,’ Coulson explained. Hulbert told the conference that the night vision goggle, thermal imaging and laser guidance operation was feasible, effective from a wildﬁre operations standpoint, and could prove valuable in delivering water safely to the ﬁre during the night when ﬁre behaviour is less volatile. THE HEAT IS ON American ﬁreﬁghters are taking their efforts around the clock, using infrared cameras, night vision goggles and laser pointers to keep up the pressure on wildﬁres after the sun has gone down. Britton Coulson, of Coulson Aircrane, the operator of the helicopters in the trial, said laser-guided night ﬂying was often less stressful, and potentially safer, than daytime operations. FSA NOV-DEC 2011 24 Now see hear Carrying a radio and using it is a pilot’s responsibility – as is knowing which frequency to use. It really is that simple. There was a time when Flight Service used to advise VFR pilots when they needed to change frequencies, but those days are gone. Today’s VFR pilots are expected to know when to change frequency and are required to use judgment, professionalism and common sense in managing frequency changes. It’s called airmanship. It is true that pilots have to deal with a communication system that can be difﬁcult to understand. This may be especially true if the pilot only ﬂies occasionally or takes a trip into unfamiliar territory. The letters page in this issue of Flight Safety Australia has a range of responses to the previous issue’s story on Lake Eyre frequency management. Many make the reasonable point that NOTAMs are far from reader-friendly documents. They are full of abbreviations and potentially misleading acronyms that date from the days when NOTAMS were transmitted in Morse code. But the NOTAM format is set by ICAO standards and is not likely to change soon. CASA aviation safety advisor for South Australia, Mal Wardrop, outlines how the issue arose: ‘In 2009, the local operators at William Creek and Marree voiced concerns to CASA about frequency congestion over Lake Eyre on 126.7. The status of the William Creek and Marree aerodromes complicated the picture, Wardrop says. ‘This NOTAM had to be issued as an ﬂight information region (FIR) NOTAM rather than one attached to William Creek and/or Marree, as these are uncertiﬁed aerodromes and as such do not have an AVFAX code in ERSA. ‘Pilots jump on to the NAIPS web site and request ‘location’ NOTAMs but neglect to select ‘FIR NOTAMs’ and therefore are not aware of the special broadcast area 127.8. They make all their radio broadcasts on the ERSA frequency of 126.7, resulting in trafﬁc conﬂicts between aircraft on the correct frequency and those on the incorrect frequency. I experienced this problem at William Creek in May this year when we were ﬁlming up there.’ Without radio, pilots must rely on unalertedsee-and-avoid. But this is fundamentally difﬁcult because it is at the limits of human visual performance, even for the sharpesteyed of pilots. In all cases, an aircraft on a collision course appears as a stationary target to the pilot and may not even be easily visible until a few seconds before impact. Even if an approaching aircraft has been seen, there is no guarantee that evasive action will be successful. 25 NOW SEE HEAR Recent incidents around Australia, and particularly in the vicinity of Lake Eyre and other hotspots suggest that some pilots are not up to scratch in this area of airmanship. A series of separation and other scares has reinforced the need for pilots to obtain and use up-to-date en-route charts. Pilots should always follow correct radio procedures and prepare thoroughly for all ﬂights by checking ERSA and NOTAMs for frequency updates and other vital information. onal ‘We raised these concerns at the Regional Airspace and Procedures Advisory Committee (RAPAC), and as a result CASA issued a legislative instrument establishing a special broadcast area on 127.8 for an area of approximately 120 nautical miles square, centred on Lake Eyre and including the aerodromes of William Creek and Marree. This allowed Airservices to issue a NOTAM to advise pilots visiting the Lake Eyre region. The status of the William Creek and Marree aerodromes complicated the picture ... this NOTAM had to be issued as an flight information region (FIR) NOTAM rather than one attached to William Creek and/or Marree, as these are uncertified aerodromes and as such do not have an AVFAX code in ERSA Recognising and responding to a collision threat does not happen instantly; and the wrong evasive manoeuvre may increase the chance of a collision. Be heard, be seen, be Watch and listen Cockpit workload and other factors can reduce the time pilots spend in trafﬁc scans. FSA NOV-DEC 2011 26 The view from most cockpits is frequently compromised by obstructions such as window pillars, and the physical limitations of the human eye mean that even regular and thorough visual scanning will not guarantee that other aircraft will be seen. Reassuringly, information from air-ground radio services, your transponder and broadcasts on the CTAF has been shown to increase your chance of detecting other aircraft in your vicinity by a factor of eight. However, whether you ﬂy into non-towered or towered aerodromes, maintaining a vigilant lookout at all times is important—you cannot rely solely on your radio. A modern gadget that can make missing a frequency change less dangerous than it would otherwise be is a dual-monitoring radio that can listen in to channels other than the one it is broadcasting on. Some modern radios offer this feature. There is good reason to take the advice of a certain Stetson-wearing television personality and ‘do yourself a favour’ by upgrading your old radio. Australian Transport Safety Bureau (ATSB) reports say that the most common airspace use and operational-related occurrence types at non-towered aerodromes are related to communication breakdowns, radio failures, relying on the radio as a substitute for effective visual lookout, misunderstandings, or insufﬁcient communication between pilots (388 of 709 occurrences between 2003 and 2008, and 148 of 222 between September 2010 and August 2011). Many of these led to reduced situational awareness of the pilot, with consequent separation issues or actual conﬂicts between aircraft. Communication issues accounted for 38 per cent of all information errors and 31 per cent of all action errors in these situations. In almost a third of them it was known (or likely) that the pilot was operating within the vicinity (10nm) of a non-towered aerodrome (a towered aerodrome becomes a nontowered aerodrome after ATC hours) but not monitoring the CTAF effectively. In 146 occurrences the pilots did not even have their radio tuned to the correct CTAF. Airspace use and operations problems are most common in the vicinity of the busiest non-towered aerodromes where radio carriage is required – Newcastle, Avalon, Geraldton, Broome, Port Macquarie, Dubbo, Mildura and Wagga Wagga – but are fairly evenly distributed across other aerodromes and aircraft landing areas of various sizes, locations and activity levels. There is really no reason to ﬂy without a radio, even in the unpopulated areas where it is still allowed. Even the smallest owner-built aircraft can have an aircraft band hand-held radio with a headset. (Paragliders use just such a radio set-up.) Without a radio, see-and-avoid – that could more accurately be called ‘maybesee-and-with-any-luck-avoid’–is a pilot’s only defence against a close encounter of the most unpleasant kind. Reassuringly, information from air-ground radio services, your transponder and broadcasts on the CTAF has been shown to increase your chance of detecting other aircraft in your vicinity by a factor of eight Be heard, be seen, be safe! Alerted see-and-avoid 101 Broadcast your intentions: Maintain a lookout for other aircraft at all times. before or during taxiing immediately before entering a runway inbound 10nm or earlier from an aerodrome immediately before joining the circuit on a straight-in approach, on final, by 3nm from the threshold on a base-join approach, before joining on base on entering the aerodrome vicinity of a non-towered aerodrome, where you intend to fly through the vicinity, but not land. Minimise non-essential chat. It is a false economy to try to avoid landing fees by sneaking quietly into an aerodrome. It will cost much more to clean up the mess if you crash. t TXJUDIFEPO t POUIFDPSSFDUGSFRVFODZHFUJOUPUIFIBCJUPG listening for the beepback) t DBOCFIFBSENPNFOUBSJMZEJTBCMFUIFTRVFMDI when setting up the radio to check that the volume is set and the headset is connected) t JTUSBOTNJUUJOHNPOJUPSZPVSSBEJPJGJUIBTB transmit indication, or do a radio check with someone nearby). Adhere to all published procedures. Make all the standard broadcasts, using the ICAO phonetic alphabet, even if you think there is no nearby traffic. 27 Concentrate while making radio calls. Do not allow yourself to be distracted by passengers, your mobile phone or your GPS. Give others the opportunity to use radio-alerted seeand-avoid by making all the standard broadcasts within 10nm of a non-towered aerodrome. Use standard procedures at all non-towered aerodromes, unless otherwise stated in the ERSA or NOTAM. Be aware that any radio-equipped aircraft could be conducting straight-in approaches at non-towered aerodromes. Avoid overflying aerodromes where possible, and maintain situational awareness of their inbound and outbound routes. Use all your systems to tell others where you are and where you are going. If in doubt, speak out! It is much better to ask for help than to end up in trouble. th tro NOW SEE HEAR Always check ERSA, NOTAMs, route charts and the weather before you fly. Check that your radio is: WIND FARMS AND WIND MONITORING TOWERS Keith Tonkin, aviation project consultant, and aviation student, Gabby O'Brien, write on the impact of wind farms on aviation Australia has a signiﬁcant potential for wind energy generation. We have both an expansive wind resource, and a growing political commitment to the development of renewable energy sources. Increasingly, for pilots navigating the Australian skies, wind farms will become a recognisable feature of the landscape. While this may break the monotony of a long ﬂight at 38,000ft, it has far greater consequences for those who ﬂy professionally below 500ft. 28 As part of a risk assessment of the effect of wind farms on aviation safety, Aviation Projects recently sponsored research by university aviation student Gabby O’Brien. The study reviewed worldwide aviation accidents associated with wind farms to identify problematic issues and to form conclusions about the likelihood of accidents arising from the hazards posed by wind farms. FSA NOV-DEC 2011 It was found that wind farms create four types of hazards to aviators: the potential for collision with a wind turbine the potential for collision with a wind monitoring tower (WMT) the potential for controlled ﬂight into terrain (CFIT) as a result of harsh manoeuvring to avoid collision with a turbine the effect on operating crew of additional planning time, additional airborne workload or imposition of operational procedures or restrictions. WIND TURBINES Wind turbines are typically located in rural Australia. They can reach heights of over 150m (492ft) at the top of the blade tip; some are currently planned to reach heights of 175m (574ft). These obstacles are highly visible during the day due to their white/off-white or pale grey marking. Where air trafﬁc is likely to be funnelled through a gap or area of lower terrain due to low cloud, it should be remembered that wind turbines are usually located on the tops of hills and therefore clear of low-level escape routes. continued on page 44 WIND MONITORING TOWERS Wind monitoring towers collect wind data by elevating anemometers some 60–90m (197–295ft) into the air. The towers however, are constructed of low-visibility galvanised metal and are anchored to the ground with near-invisible guy wires. They can be in place for a number of years before wind turbines are erected on a wind farm site. WORLDWIDE ACCIDENTS/INCIDENTS The study analysed aviation accidents and incidents recorded since 2000. The eight cases all occurred during day operations in Canada, France and the USA, and include: 1. VFR aircraft struck by wind turbine blades. In this case, the accident occurred during the day in conditions of low cloud (cloud base estimated to be between 50m (164ft) and 100m (328ft)) and signiﬁcantly reduced visibility (estimated to be between 400m and 800m) in fog. The turbine was 120m (393ft) AGL high. Incredibly, the aircraft was struck twice (once on each wing tip) by separate wind turbines, but landed safely. The photos below show the damage caused to the aircraft and a plot of the aircraft track through the wind farm, which was clearly indicated on the aeronautical chart used by the pilot. Wind turbine at Oaklands Hill Wind Farm, Victoria 29 2. Fatal loss of control of a VFR aircraft while manoeuvring around wind turbines (CFIT) 3. Fatal ﬂipping of an idling helicopter due to excessive tailwind gusts WIND FARMS 4. Fatal power line strike during animal control culling 5. Private ﬂight fatally collided with a WMT 6. Aerial agricultural aircraft fatally collided with a WMT 7. Aerial agricultural aircraft collided with a WMT (see photo below right) 8. Aerial agricultural aircraft fatally collided with a WMT. Wind monitoring tower at Oaklands Hill Wind Farm, Victoria Damaged VFR aircraft from blade strike and ﬂight path (Source: BEA) Damaged Air Tractor after WMT collision (source: Transport Canada) Tool control at a glance Organisation t5PPMUSBZToNPSFUIBOQBDLBHJOH BCVJMUJOTUPSBHFTZTUFN t4UBOEBSEGPBNLJUToBMMUIFNBUFSJBMT SJBMTT BOEUPPMTJOBOFBTZUPVTFLJU Visibility FSA NOV-DEC 2011 30 t$PMPVSDPOUSPMoIJHIWJTJCJMJUZ DPMPVSTGPSTQFDJBMOFFET t8BMMNPVOUFEUPPMDPOUSPMCPBSET oTUBOEBSEBOEDVTUPNUPNFFU ZPVSOFFET t1SPGSFTTJPOBMMZFOHJOFFSFEGPBN DVUMBZPVUT Security t5PPMDIJUToDBSEBOESFBEFSTZTUFN t1PDLFUCBEHFToNBSLBOEJEFOUJGZGPBNLJUT t5SVF'JU7JSUVBM*OWFOUPSZoDPNQVUFSBJEFE UPPMMBZPVUT t,FZMFTTDPOUSPMoDBSETOPULFZToGPSCFUUFS TFDVSJUZBOEDPOUSPM Trackability t-BTFSUPPMFOHSBWJOHoUPNBUDI ZPVSJEFOUJåDBUJPOTZTUFN t4QFDJBMJTFELJUToCPYFTUPCBHTUP NBUDIZPVSOFFET Accountability t#BSDPEFSFBEFSToCFUUFSBDDFTTDPOUSPM t5VSOLFZMJTUTUPMBZPVUToDPNQVUFS BTTJTUFEGPSTQFFEBOEBDDVSBDZ t4PGUXBSFDPOUSPMBOESFQPSUJOHoUIF VMUJNBUFPODPOUSPMBOESFDPSELFFQJOH Tool Control System Phone: 1800 811 480 Web: www.snapontools.com.au/industrial PULL-OUT SECTION Nobody’s playing consequences The arrival of QF2 at Bangkok Suvarnabhumi Airport on 7 January 2008 will probably never make those melodramatic but compelling air crash TV programs. That’s because, on the surface, not much happened. But it was far from an innocuous event. Late last year the Australian Transport Safety Bureau issued a report into the incident. For anyone with even a passing knowledge of aviation safety its 99 pages are as horrifying as anything by Stephen King. The Boeing 747-400 was at ﬂight level 210 on descent into Bangkok Airport when the cabin service manager told the pilots about a large water leak in the forward galley. The ﬁrst indication of electrical trouble came two minutes later: a bus control unit status message on the engine indicating, and a crew alerting system (EICAS) display. AIRWORTHINESS A close call for a Qantas long-haul flight has lessons for anyone who maintains an aircraft. The tiniest things can have enormous results, sometimes many years later, write Roger Alder and Robert Wilson. 31 Location of galley and main equipment centre Source: ATSB Seven minutes after that, as the aircraft was descending through 10,000ft for a landing at Bangkok, came the ﬁrst of a cascade of system failures. In rapid succession three of the four alternating current (AC) buses lost power, the auto-throttle disconnected, the autopilot disengaged, several fuel pumps ceased operating, the weather radar shut down, the cabin air conditioning and pressurisation systems failed and the ﬁrst ofﬁcer’s electronic ﬂight instrument system (EFIS) displays went blank. There were between three and ﬁve pages of messages on the EICAS display, although its lower screen had also gone blank. It was later found that most of the 747’s electrically powered systems had stopped working because three of the four generator control units that managed the AC buses had failed. ‘This goes with this goes with that’ ... PULL-OUT SECTION It’s a phrase any engineer modifying a system should keep in mind as they contemplate making a change, however slight. FSA NOV-DEC 2011 32 (They were automatically shut down as a result of internal faults.) The systems that still worked were running on power from the fourth AC bus, or on emergency battery power. Because the electrical bus tie breakers for buses 1, 2 and 3 had been left disconnected by the shut down, the fourth bus was unable to transfer power to them. Similarly, the generator control breakers were disconnected, cutting the three dead buses off from their respective engine-driven generators. The direct current (DC) buses were able to be powered by DC bus 4, which was powered by a transformer/rectiﬁer linked to AC bus 4. The aircraft’s systems that could take power from the standby bus, battery buses, AC bus 4, or the DC buses still worked, although some of these were now operating in a degraded mode. All aircraft systems powered through the other AC buses were unavailable. The auxiliary power unit, the so-called ‘ﬁfth engine’ that powers electrical systems when the aircraft is on the ground, could not be started in ﬂight. The aircraft landed 21 minutes after the ﬁrst electrical failure, with about 16 minutes of assured battery time remaining. The crew and passengers were lucky. There were several signiﬁcant factors strongly in their favour: it was daylight, the skies were clear with light winds, and the aircraft was not only close to its destination airport, it was ﬁrst in the queue to land. One chilling detail is that the same aircraft had been on an Antarctic charter trip a week earlier. It doesn’t take a particularly vivid imagination to consider what would have happened if the same sequence of failures had occurred over an icecap at the bottom of the world. The ATSB report pulls no punches: ‘Had the event occurred more than 30 minutes ﬂying time from the nearest suitable airport, or Forward galley (typical aircraft) Source: ATSB if there had been a delay prior to landing, numerous ﬂight-critical systems would have subsequently become unavailable’, it says. These would have included autopilot, communications and instrument systems, and would have reduced the crew to ‘ﬂying by hand with only visual and tactile references, a standby airspeed indicator, a standby magnetic compass and a standby altimeter with degraded reliability to guide them’ the ATSB said, noting that the risk of spatial disorientation and resulting loss of control in such conditions would have been ‘particularly acute’. ‘Personal mobile telephones’ would have been the only source of air-to- ground communications. The ATSB found that the incident was indeed related to the puddle of water that the cabin service manager had reported. How it came to jeopardise 346 passengers and 19 crew is a fascinating and cautionary tale for anyone who works on, or ﬂies, an aircraft of any size. The investigation found that water had probably overﬂowed from the aircraft’s forward galley ﬂoor drain as a result of a blockage in that drain, possibly due to ice forming in or near the drain mast. The water had ﬂowed forwards, through a gap beneath the forward galley bulkhead and a gap in the decompression panel, into the space where the bus controllers were housed. Signs of long-term water damage were found on three of the generator control units. To reach these units the water had probably entered the gutter of a dripshield and leaked through the joints at each end, and possibly through cracks around the dripshield’s fasteners. The ATSB report listed other similar incidents. A US Boeing 747 had ﬂight control anomalies following a water leak in the cabin; an Irish Airbus A300 had multiple system failures on a night instrument approach after a leak caused by a frozen water tank; there were several cases of electrical ﬁres in DC-9s caused by leaks from the forward toilet; and a Boeing 737 began ‘uncommanded roll and yaw oscillations,’ after water got into its avionics compartments. In the three years following the Bangkok incident there were four other minor incidents involving water leaks in Qantas or ex-Qantas aircraft. It had dripped onto a brace on the top of the equipment rack, and travelled along that brace and into the electrical equipment, through ventilation holes in the top of the equipment. Qantas inspected its 747 ﬂeet and found 18 damaged dripshields in 30 aircraft. There were also 12 damaged drain line heaters. Those heaters only had to be inspected at every 12-yearly D check, which in the case of the aircraft involved would have been about four years before the incident. The ATSB concluded that the location of a decompression panel (installed by Qantas) and absence of cabin ﬂoor sealing above where the generator control units were situated ‘increased the risk of liquid ingress into the aircraft’s electrical systems’. The sealing around the wet galley area was not adequate but was unlikely to have contributed to the problem, it found. The decompression panel comprised a hinged panel that was held shut with a spring, and had a perimeter gap of about 3mm. At least one of the seeds for this frightening incident had been planted years earlier, the ATSB found. Boeing 747-400s originally came from the factory with two outlets for the main and upper deck drains (these drained waste water overboard from galleys, galley drains, lavatory wash basins, and drinking fountains). But that system left water marks on the outside of the fuselage, so Qantas replaced it with a longer drain mast that had only one outlet. The two drain lines were combined with a rubber Y-section into the single outlet. This engineering change had been applied to all the Qantas 747 ﬂeet by 1992. The airline installed a water barrier at the rear of the forward galley bulkhead on all its 747-400s. It also applied more sealant to protect the decompression panel. Boeing issued service letters and service bulletins, and the Federal Aviation Administration (FAA) issued airworthiness directives requiring inspection and improvement of the dripshields on various 747 versions. But this is not just a story about water: it’s also about systems and how they interact. The abstract concepts of redundancy, parallel systems and avoidance of single point failures are important. continued on page 41 33 AIRWORTHINESS Forward galley area with bulkhead and ﬂoor panels removed (typical aircraft) Source: ATSB PULL-OUT SECTION It is easy to be critical in hindsight, but it is also obvious that the change required one drain outlet to do the work of two drain outlets. A tiny bit of parallel separation or redundancy had been taken out of the 747’s design. SELECTED SERVICE DIFFICULTY REPORTS 1 August 2011 – 15 September 2011 Note: Similar occurrence figures not included in this edition AIRCRAFT ABOVE 5700kg Airbus A320232 Main landing gear door actuator failed. SDR 510013537 RH main landing gear door actuator slow in operation. P/No: 114122012. TSN: 9,244 hours/5,191 cycles. PULL-OUT SECTION Airbus A330202 Cargo smoke detection activated. SDR 510013332 Forward cargo smoke detection warning. Cargo fire bottles fired. Investigation continuing. FSA NOV-DEC 2011 34 Airbus A330202 Passenger service unit oxygen mask door failed test. SDR 510013379 Passenger Service Unit (PSU) 37DEFG oxygen mask door would not open due to one latch failing to unlock. Investigation continuing. P/No: 65C1505B0020005. Airbus A330203 Landing gear brakes suspected faulty. SDR 510013497 Brakes would not release after park brake disengaged. Investigation could find no definitive cause for the defect but the brake steering control unit (BSCU) was changed as a precaution. Airbus A330303 Crew oxygen system low pressure. SDR 510013507 Crew oxygen system lost pressure. Nil indication of pressure loss. Investigation continuing. Airbus A380842 Passenger service unit oxygen manifold cracked/leaking. SDR 510013371 Numerous passenger service unit (PSU) oxygen manifolds cracked. See attachments for a list of affected items. Investigation continuing. BAC 146200A APU firewall cracked. SDR 510013563 APU firewall cracked in two places. Found during inspection iaw AD/BAE146/053. Investigation continuing. Boeing 717200 Aircraft lightning strike – elevator trailing edge. SDR 510013325 Aircraft struck by lightning. Investigation found RH elevator trailing edge rivet burnt. Boeing 717200 Aircraft over-speed. SDR 510013483 Aircraft suffered an over-speed during descent in turbulence. Over-speed inspection could find no damage. Boeing 717200 APU carbon seal leaking – cabin smell. SDR 510013310 Slight smell in cabin. Caused by APU carbon seal leaking. Boeing 737376 Horizontal stabiliser jackscrew unserviceable. SDR 510013290 Horizontal stabiliser jackscrew assembly unserviceable. Jackscrew was unable to be correctly lubricated with discoloured grease from the lower seal but nil grease from the upper seal or grease vent. P/No: 654997025. TSN: 59,593 hours. TSO: 2,965 hours. Boeing 737476 Co-pilot’s sliding window outer pane cracked/arcing. SDR 510013300 First Officer's No. 2 sliding window outer pane cracked and arcing.P/No: 5717623096. TSN: 503,860 hours. TSO: 503,860 hours. Boeing 737476 Elevator tab assemblies incorrectly fitted. SDR 510013375 Suspect incorrect installation of LH and RH elevator tab assemblies. Found during inspection iaw EI 7370055-0025 R04. Investigation continuing. Boeing 737476 Fuselage ram air fairing blowout panel missing. SDR 510013416 LH ram air fairing blowout panel missing/separated. P/No: 6548675165. Boeing 7374L7 Galley oven fumes. SDR 510013471 Fumes from rear galley. Investigation found No. 2 oven C304 faulty. P/No: GENM2585015. TSN: 48,359 hours. TSO: 12,246 hours. Boeing 737838 Aileron and rudder trim module faulty. SDR 510013498 Nil LH rudder trim. Investigation found a faulty aileron and rudder trim module. Investigation continuing. P/No: 697370313. Boeing 737838 Electric hydraulic pump unserviceable. SDR 510013339 System 'B’ electric hydraulic pump internal short circuit. Investigation found AC motor phases shorting to ground case drain. P/No: 887477. TSN: 24,453 hours. TSO: 24,453 hours. Boeing 737838 Elevator mast and output torque tube crank arm bearings worn. SDR 510013356 LH and RH elevator mast and output torque tube crank arm bearings worn beyond limits. Both bearings had approximately 7.62mm (0.3in) free-play. Limit 5.33mm (0.210in). Boeing 737838 Spoiler actuator faulty. SDR 510013297 No. 4 spoiler actuator faulty causing spoiler to vibrate during operation. P/No: 251A12403. TSN: 31,746 hours. TSO: 31,746 hours. Boeing 7378FE Landing gear door partially open. SDR 510013437 Landing gear failed to retract following take-off. Investigation found the landing gear manual extension access door not fully closed and access door microswitch out of adjustment. Boeing 737BBJ Cockpit windows cracked. SDR 510013417 Both cockpit No. 2 windows cracked in vinyl interlayer. No. 4 and No. 5 windows have discolouration and cracking of urethane interlayer. Found during inspection iaw IE-056-0101R01. Boeing 747 Wing trailing edge flap skin delaminated. SDR 510013571 (photo below) LH outboard trailing edge flap skin delaminated and separated in flight. Area of skin loss approximately 2.43m by 0.6m (8ft by 2ft). Aircraft overseas registered. Boeing 737838 Engine bleed air cabin fumes. SDR 510013433 Fumes in cabin. Investigation found compressor wash had been carried out overnight. Boeing 737838 Engine bleed air pre-cooler control valve faulty. SDR 510013560 RH engine bleed air system pre-cooler control valve faulty. P/No: 32895625. TSN: 14,898 hours. TSO: 7,318 hours. Boeing 737838 Engine spar valve motor failed. SDR 510013528 No. 2 engine spar valve electric motor failed. P/No: MA30A1001. TSN: 312 hours. TSO: 312 hours. Boeing 737838 Horizontal stabiliser jackscrew metal contamination. SDR 510013295 Horizontal stabiliser jackscrew grease contaminated with metal particles. Initial investigation found plating coming off. Found during investigation iaw EI N37-27130R2. Investigation continuing. Boeing 737838 Nose landing gear bushing faulty. SDR 510013499 Nose landing gear release roller failed to return to the retract position. Release roller/cam roller connecting shaft seized. Following rectification the roller still failed to return to the correct position. Suspect bushings still providing too much friction. Investigation continuing. Found during nose landing gear manual extension test iaw EW-2474931. Boeing 737838 Nose landing gear release assembly failed. SDR 510013450 Nose landing gear manual extension release assembly failed. Investigation found bolt was tight but had wound out approximately 6.3mm (0.25in) and was contacting stop on the cam unit, preventing operation. P/No: 273A45102. Boeing 737838 Nose landing gear release roller failed to reset during test. SDR 510013572 Nose landing gear release roller failed to reset following manual extension test iaw EA: MM04719. Boeing 737838 Nose landing gear spring broken. SDR 510013510 Nose landing gear manual extension spring broken. Boeing 737838 Passenger seat belt signs wires burnt. SDR 510013418 Passenger seat belt signs located at seats 12 to 15 DEF unable to be switched off due to burnt and unsecured earth lugs for wires W6242-2431B-18, W62422432B-18 and W62422433b-18. Boeing 74748E Engine uncommanded thrust increase. SDR 510013419 No. 1 engine uncommanded thrust increase to 106.4 per cent. Investigation continuing. Boeing 747438 Flight deck emergency door handle incorrectly assembled. SDR 510013466 Flight deck emergency exit door handle fitted with incorrect orientation. Handle was indicating ‘open’ when ‘locked’ and vice versa. Boeing 747438 Main landing gear tyre separated. SDR 510013381 Body landing gear No7 main wheel tyre tread separated. Damage to fuselage and hydraulic lines. Landing gear tilt problem. Investigation found a steel rod approximately 279mm long by 19.05mm in diameter (11in by 0.75in) amongst the tyre debris on the runway. The rod was identified as being an item of tooling used during tyre to wheel mounting by the wheel maintenance service provider. Boeing 747438 Override/jettison pump discharge pipe flange cracked. SDR 510013316 Uncommanded fuel transfer. Investigation found the 3M tank forward override/jettison pump discharge line mating flange circumference cracked at the discharge check valve interface. Crack length approximately 95.25mm (3.75in). Boeing 767336 Auto-flight system controller failed. SDR 510013541 Nil autopilot function. Mode selection panel (MSP) frozen. Investigation continuing. P/No: 6224717003. Boeing 767336 Engine frame support fairing missing. SDR 510013473 RH engine LH ‘A’ frame support fairing partially missing. Missing piece approximately 127mm (5in). Boeing 767336 Main landing gear failed to retract. SDR 510013451 RH main landing gear failed to retract. Investigation continuing. Boeing 767338ER Hydraulic motor generator controller incorrectly wired. SDR 510013552 LH and RH hydraulic motor generator (HMG) controller connectors transposed. Investigation continuing. SELECTED SERVICE DIFFICULTY REPORTS ... CONT. Lear 35A Main landing gear up limit switch out of adjustment. SDR 510013353 LH main landing gear up limit switch (S5) out of adjustment. P/No: 1CH16. Bombardier DHC8102 Cargo hold smoke detector unserviceable. SDR 510013562 No. 2 cargo hold smoke detector unserviceable. Investigation found the detector had a slight amount of charring/burning on the external casing. A slight carbon deposit was also found on the protective grill. Investigation continuing. P/No: 47359714. Bombardier DHC8202 Auxiliary fuel tank pump faulty. SDR 510013491 No. 1 auxiliary fuel tank pump faulty and failing to transfer fuel. Investigation continuing. Bombardier DHC8102 Engine oil cooler cracked and leaking. SDR 510013348 (photo below) LH engine oil cooler cracked longitudinally through weld. Loss of engine oil. P/No: 28E997. Bombardier DHC8402 Wing attachment bolt barrel nut unserviceable. SDR 510013327 RH forward inboard wing attachment bolt barrel nut loose. See attachment for investigation details. TSN: 5,573 hours/6,355 cycles. Bombardier DHC8202 Starter-generator suspect faulty. SDR 510013555 No. 2 engine starter-generator suspect faulty. Investigation continuing. P/No: 23088008. Bombardier DHC8315 Flight control system faulty. SDR 510013405 Flight control system faulty. Stick pusher and stall warning system failure. Bombardier DHC8315 Nose landing gear actuator hose leaking. SDR 510013501 Nose landing gear drag strut actuator flexible hose leaking. P/No: DSC252B40124. TSN: 9,006 cycles. Bombardier DHC8402 Ice and rain protection systems heater damaged. SDR 510013320 (photo below) Engine intake adapter heater damaged due to overheating during operation. Evidence of possible flame generation. Investigation continuing. TSN: 5,796 hours. TSO: 6,640 hours. Embraer ERJ190100 APU oil system metal contamination. SDR 510013559 APU oil system chip detector metal contamination. Metal particles found to be larger than 0.15mm (0.006in). Investigation continuing. TSN: 1,849 hours/2,424 cycles. Embraer ERJ190100 Flap lower outboard control rod distorted. SDR 510013557 Flap over-speed. Investigation found LH and RH flap lower outboard control rods P/No: 92387-901 and P/No: 92385-901 bent. P/No: 92387901. Embraer ERJ190100 Integrated pitot/static/AOA sensor unserviceable. SDR 510013269 Integrated pitot/static/AOA sensor 3 unserviceable. P/No: 2015G2H2H8A. TSN: 2 hours/1 cycle. Embraer ERJ190100 Passenger service unit oxygen latch release tool broken. SDR 510013282 Passenger service unit (PSU) oxygen latch release tool probe broken. Manual deployment of oxygen masks affected. 35 AIRCRAFT BELOW 5700kg Beech 200 Dual bus feeder diodes failed. SDR 510013545 No. 2 dual bus feeder diodes failed at anode connection. See attachment for investigation and rectification details. P/No: 70HF10. Beech 200 Electrical bus feeder diode faulty. SDR 510013479 No. 2 electrical bus feeder diode CR2 breaking down internally due to loose anode. P/No: 70HF10. Beech 200 Flap drive shaft sheared. SDR 510013481 RH inboard flap driveshaft sheared at gearbox end. Suspect caused by incorrect rigging. P/No: 1013800002. TSN: 226 hours/228cycles/4 months. Beech 200 Wing leading edge skin cracked. SDR 510013366 (photo below) RH wing upper leading edge skin cracked in area adjacent to upper forward wing attachment fitting inboard screw. Crack located between Stn 124.616 and Stn 147.735. P/No: 00011010916. TSN: 12,706 hours/15,241 landings. Fokker F27MK50 Propeller blade de-ice boot burnt. SDR 510013464 LH propeller blade de-ice boot burnt. Fokker F28MK0100 Autopilot system failed. SDR 510013472 No. 2 autopilot system failed. Investigation continuing. Bombardier DHC8402 Main landing gear wheel tie bolt loose. SDR 510013322 (photo following) RH main landing gear inboard wheel tie bolt loose. Found during inspection iaw MA-3247-Q400. TSN: 7,799 hours/9,015 cycles. TSO: 132 hours/138 cycles. Fokker F28MK0100 Co-pilot’s windshield cracked. SDR 510013573 First officer's windshield cracked. Pilot's vision obscured. TSN: 2,976 hours/2,369 cycles. TSO: 2,976 hours/2,369 cycles. Fokker F28MK0100 Elevator cable tension regulator bearing excessive play. SDR 510013273 Elevator cable tension regulator LH bearing bellcrank excessive play. P/No: D78179707. Beech 200 Wing spar attachment fitting barrel nut incorrectly assembled. SDR 510013502 RH outer wing main spar upper attachment fitting barrel nut bore damaged (gouged). Investigation found damage caused by an incorrectly assembled barrel nut. Found during inspection iaw SIRM 57-17-02 and AD/ Beech200/38. P/No: 80691CF1216. TSN: 12,895 hours/15,464 landings. AIRWORTHINESS Bombardier DHC8202 Hydraulic line damaged. SDR 510013477 Flexible hydraulic line split and leaking. Loss of hydraulic fluid. Line is located in area of No. 1 engine cowling. P/No: DSC252D40134180. Embraer ERJ170100 Engine PRSOV unserviceable. SDR 510013368 LH engine HP and LP pressure regulating and shutoff valves (PRSOV) have suspect excessive blow-by causing erratic engine ITT indications. Investigation continuing. P/No: 10012461X2OFF. TSN: 10,378 hours/8,116 cycles. Saab SF340B Nose landing gear strut retraction pin fractured. SDR 510013544 (photo below) Nose landing gear strut retraction pin fractured and partially withdrawn from cylinder. Suspect caused by hydrogen embrittlement due to corrosion. P/No: AIR127298. TSN: 25,173 cycles. TSO: 11,991 cycles. PULL-OUT SECTION Embraer EMB120 APU bleed air duct corroded. SDR 510013398 (photo below) APU bleed air duct had severe corrosion and numerous holes under insulation layers. P/No: 12044169001. Saab SF340B Landing gear control CB wire worn and damaged. SDR 510013278 Landing gear control circuit breaker power wire GA401-1601 and adjacent wires chafed and arcing causing damage to cockpit frame FSTN 200. Wiring installed as part of SB 32-120 in June 2000. Investigation continuing. P/No: GA4011601. SELECTED SERVICE DIFFICULTY REPORTS ... CONT. Gulfstream 500S Pilot’s rudder pedal bolt loose. SDR 510013546 Pilot's LH rudder pedal attachment bolt loose. Beech 58 Aircraft emergency window partially open in flight. SDR 510013456 RH emergency exit window opened during flight. Inspection found no fault with the latching system and it is suspected that a passenger might have been leaning on the window. Jabiru 170CLSA Landing gear brakes locked up. SDR 510013533 Brakes locked during landing. Pilot decided to go around but a wheel contacted a fence at the end of the runway and the aircraft crashed. Aircraft registered with Recreational Aviation Australia. TSN: 49 hours. Britten Norman BN2A20 Landing gear brake caliper failed. SDR 510013440 RH brake caliper failed at attachment pins. P/No: 3023D. PULL-OUT SECTION Britten Norman BN2A21 Engine air intake duct unserviceable. SDR 510013547 Engine air intake duct unserviceable. Found during inspection iaw AD/BN2/057. P/No: TU195MM660MMCC. Cessna 172N Cigarette lighter resistor burnt. SDR 510013478 Cigarette lighter voltage dropping resistor shortcircuited and burnt. P/No: S20415016. TSN: 13,367 hours. Cessna 172S Aileron cable worn. SDR 510013514 RH aileron cable in roof area worn. P/No: MC0510105362. TSN: 1,338 hours. Cessna 182E Pilot’s control column bearing failed. SDR 510013387 (photo below) Pilot's control column support bearing failed. Investigation found needles unserviceable. P/No: 0760633-1. TSN: 12,434 hours. Cessna 402C Elevator control system suspect faulty. SDR 510013540 Elevator control system suspect faulty. Investigation checked for FOD and cable tensions with no adverse results found. System checked serviceable. Cessna 402C Main landing gear torque link washer missing. SDR 510013313 RH main landing gear torque link and bush separated. Initial investigation found there were no washers fitted under the split pinned bolt. Investigation continuing. P/No: 50450182. Jabiru J230DL Engine throttle cable seized. SDR 510013531 Engine throttle seized in open position during engine start. Aircraft moved of its own accord and sustained a damaged wing and broken propeller as it crashed into the door of a nearby hangar. Investigation found a protruding grub screw on the throttle rod prevented the throttle from being retarded. Aircraft registered with Recreational Aviation Australia. TSN: 165 hours. Pilatus PC12 Flap attachment arm cracked. SDR 510013377 (photo below) LH flap inboard attachment arm assembly cracked in area of upper fork end. P/No: 5275212153. TSN: 10,244 hours/13,381cycles/131 months. Cessna M337B Wing fuel line corroded. SDR 510013358 LH wing fuel line located between spar union and sump tank had pinhole corrosion. P/No: 140010625. 36 FSA NOV-DEC 2011 Cessna 402C Elevator actuator chain sprocket jammed - FOD. SDR 510013527 Loss of full elevator-up movement. Investigation found a small ‘rivet nail’ approximately 5mm by 1.5mm (0.19in by 0.05in) jammed in the actuator chain sprocket. Full movement restored when FOD removed. P/No: PA495A2. Diamond DA40 Electric pedal adjuster broken. SDR 510013470 LH electric pedal adjuster failed. Investigation found the rubber drive belt had missing teeth. Driven gear also had two missing teeth. P/No: D6027233021. TSN: 104 hours. Cessna 208 Landing gear brake line end fitting on float failed. SDR 510013281 LH brake line end fitting on float failed. Loss of hydraulic pressure. Cessna 208B Trailing edge flap tube nuts loose. SDR 510013489 RH trailing edge flap interconnect tube nuts loose. During rigging check, the drive rods from the bellcranks to the flaps were also found to be binding. TSN: 341 hours. Cessna 210M Horizontal stabiliser attachment fitting cracked. SDR 510013566 (photo below) Horizontal stabiliser attachment fitting cracked. P/No: 12324001. Diamond DA42 Elevator lever cracked. SDR 510013280 Elevator lever cracked from forward elevator attachment point extending approximately 25mm (1in) forward and approximately 40mm (1.57in) rearward of the hole. Crack extended approximately 75 per cent of the depth of the lever. P/No: D42735301. TSN: 1,569 hours. Gippsland GA8 Pitot tube heater connector faulty. SDR 510013574 (photo below) Pitot tube heater connector burnt/damaged. P/No: GA8341001. Pilatus PC12 Flight control warning unit failed. SDR 510013409 Flap control warning unit failed. P/No: 9787320017. TSN: 7,265 hours/5,754 landings. Piper PA28140 Wing spar cap corroded. SDR 510013426 LH wing inboard spar lower spar cap had exfoliation corrosion for approximately100mm (4in). P/No: 620706. TSN: 6,705 hours. Piper PA31350 Flap flexible drive shaft failed test. SDR 510013400 RH trailing edge flap flexible driveshaft failed measurement test iaw AD/PA31/101-3. P/No: 00486597. TSO: 500 hours. Piper PA31350 Wing aileron spar corroded. SDR 510013411 RH aileron spar corroded underneath balance weight. Found during inspection iaw AD/PA31/118-2. TSO: 500 hours. Piper PA31 Main landing gear torque link broken. SDR 510013482 LH main landing gear torque link broken. P/No: 40256. Piper PA34200T Hydraulic power pack unserviceable. SDR 510013272 Hydraulic power pack unserviceable. P/No: HYC5005. Gulfstream 114 Elevator spar cracked. SDR 510013538 (photo below) RH elevator spar cracked in area located just below the outboard hinge. P/No: 4421110. TSN: 2,500 hours. Cessna 210N Horizontal stabiliser rear bracket broken. SDR 510013553 (photo following) LH horizontal stabiliser rear bracket P/No: 1232400-1 broken. During investigation, the RH rear bracket P/No: 1232400-2 was also found to be cracked. P/No: 12324001. Swearingen SA227AC Engine oil tube cracked and leaking. SDR 510013365 RH engine oil line between propeller governor and negative torque signal (NTS) cross assembly cracked adjacent to flared end. Loss of engine oil pressure. P/No: 31080811. Swearingen SA227DC Electrical system wire broken. SDR 510013485 Wire from terminal 6 on terminal strip TS 311 broken resulting in loss of nose wheel steering and failure of landing gear to extend. P/No: 200007AB22. TSN: 13,934 hours/17,129 cycles/17,129 landings/220 months. TSO: 13,934 hours/17,129 cycles/17,129 landings/220 months. SELECTED SERVICE DIFFICULTY REPORTS ... CONT. Swearingen SA227DC Landing gear failed to extend. SDR 510013487 Landing gear failed to extend on selection. Approximately 20 seconds later it extended normally. TSN: 25,622 hours/26,361 cycles/26,361 landings/209 months. TSO: 25,622 hours/26,361 cycles/26,361 landings/209 months. Eurocopter BK117C2 Main transmission oil filter metal contamination. SDR 510013404 Main transmission chip light illuminated. Investigation found excessive metal contamination in oil filter. P/No: B632K1001051. TSN: 814 hours/2,524 cycles/2,524 landings/33 months. TSO: 814 hours/2,524 cycles/2,526 landings/33 months. ROTORCRAFT Robinson R22BETA Main rotor blade debonded. SDR 510013506 Main rotor blade skin debonded on lower surface in the area of the blade tip. Debond area approximately 20mm by 10mm (0.78in by 0.39in). Found during tap testing iaw AD/R22/54 Amdt1 and FAA 2011-12-10. Investigation continuing. TSN: 318 hours. Agusta Westland AW139 Main rotor servo actuator pressure switch unserviceable. SDR 510013407 No. 1 main rotor servo actuator No. 2 system pressure switch unserviceable. P/No: 7079785. TSN: 174 hours/339 cycles/339 landings/12 months. TSO: 174 hours/339 cycles/339 landings/12 months. Agusta Westland AW139 Tail rotor blade cracked. SDR 510013462 Tail rotor blade cracked in area of composite attachment. Found during inspection iaw EASA AD 2011-0156-E. P/No: 3G6410A00131. TSN: 138 hours. Bell 412 Pilot’s collective stick throttle linkage over lubricated. SDR 510013403 Pilot's collective stick throttle linkage system over-lubricated, causing eventual sticking of gears/linkages. P/No: 212001164129. TSN: 58 hours. Robinson R44 Main rotor drive transmission failed. SDR 510013422 Transmission failed during flight resulting in loss of drive between engine and main rotor. During autorotation, the aircraft landed heavily, causing the skids to spread and the main rotor to strike the tail boom. Initial investigation of the transmission chip detector found a significant amount of metal. Investigation continuing. P/No: C0065. TSN: 2,037 hours. TSO: 2,037 hours. Robinson R44 Main rotor drive systems split pin missing. SDR 510013423 Main rotor gearbox input coupling yoke assembly nut cotter pin missing. P/No: MS24665210. Robinson R44 Tail rotor blade skin cracked. SDR 510013539 (photo below) Tail rotor blade skin cracked. P/No: C0292. TSN: 1,168 hours. Jabiru 2200 Engine through bolt broken. SDR 510013529 Engine through bolt broken. Bolt located between No. 3 and No. 4 cylinders. Aircraft registered with RAA. TSN: 130 hours. Jabiru 2200J Engine through bolt undersize. SDR 510013436 Replacement engine through bolts approximately 0.254mm (0.010in) undersize. P/No: 4291044. Lycoming AEIO360B2F Engine FCU servo contaminated. SDR 510013267 Fuel control unit (FCU) servo contaminated with green sludge from fuel dye. P/No: 252429111. TSO: 417 hours. Lycoming IGSO480A1E6 Engine crankcase cracked and leaking. SDR 510013520 LH engine LH crankcase half cracked in area between No. 4 and No. 6 cylinders adjacent to No. 6 cylinder forward upper cylinder base stud. P/No: 75355. TSO: 76 hours/38 cycles/38 landings/ 4 months. Lycoming IO540AC1A5 Engine fuel injector line cracked. SDR 510013567 Engine forward LH upper fuel injector line cracked. TSN: 648 hours. Eurocopter AS332L Intermediate gearbox fairing cracked. SDR 510013367 Intermediate gearbox fairing cracked. Found during inspection iaw AD 2011-0129-E. P/No: 332A2403030601. Lycoming IO540K1B5 Engine exhaust tailpipe separated. SDR 510013434 RH engine tailpipe separated and fell into water. P/No: NB53235. TSN: 1 hour. TSO: 1 hour. Eurocopter AS365N Main rotor servo controller diode failed. SDR 510013394 Main rotor servo control connection box P/No: 800646 faulty. Investigation found a failed diode in circuit board P/No: 802170 and moisture ingress from the cracked connection box. P/No: 800646. TSN: 1,530 hours. TSO: 1,530 hours. PISTON ENGINES Eurocopter AS365N Tail rotor hub to blade torsion bar cracked. SDR 510013543 (photo below) Tail rotor hub to blade torsion bar had one laminate cracked and separated. P/No: 365A33352700. TSN: 6,586 hours. Continental IO360D Engine injector line worn. SDR 510013357 Rear engine injector lines Nos. 1, 2, 4 and 5 P/No: 630657, P/No: 630658, P/No: 630650 and P/No: 630651 worn beyond limits. Found during inspection iaw AD/Con/60. P/No: 630657. Continental IO520L Engine magneto seized. SDR 510013430 RH magneto seized. Metal contamination of engine. P/No: 103493505. TSO: 166 hours. Jabiru 2200 Engine cylinder inlet valve separated. SDR 510013535 (photo following) No. 2 cylinder inlet valve separated from valve stem causing internal damage. Valve stem seized in valve guide. Aircraft registered with RAA. P/No: 2200. TSN: 764 hours. Lycoming IO580B1A Engine oil filter metal contamination. SDR 510013372 Following fitting of new engine, during test flight the oil pressure was seen to bleed off. Suspected contamination of oil pressure relief valve. Investigation found some non-ferrous metal flakes in the oil filter. Lycoming LTIO540J2BD Engine cylinder exhaust valve damaged. SDR 510013565 RH engine No. 6 cylinder exhaust valve cracked and broken with several pieces missing. P/No: LW16740. TSN: 1,066 hours. Lycoming O235H2C Engine spark plugs/magneto suspect faulty. SDR 510013522 Engine vibration and misfiring soon after take-off. Unable to duplicate fault on the ground. Magneto replaced but tested serviceable. Spark plugs suspected to be breaking down at high RPM. All plugs bench tested as serviceable but were replaced as a precaution. P/No: REM37BY. Lycoming O360A1A Engine big end bearing delaminated. SDR 510013314 No. 4 connecting rod big end bearing delaminating. Metal in oil filter. TSN: 368 hours. 37 AIRWORTHINESS Bell 212 Elevator horn support bracket cracked. SDR 510013323 LH elevator horn support bracket cracked for approximately 50mm (1.96in). Investigation found the support frame P/No: 205-030-820-015 had been replaced with the original six aft rivets being replaced with Cherry Max rivets P/No: CR3243-5 that had not pulled up correctly, allowing the bracket to move. P/No: 205030889015. TSN: 2,652 hours. Robinson R44 Main rotor drive systems drive belt partially separated. SDR 510013265 Engine to transmission drive belt beginning to separate at join. P/No: A1903. TSN: 102 hours. Jabiru 2200 Engine failed. SDR 510013526 Engine failed. Engine made a loud noise followed by power loss. Aircraft badly damaged during emergency landing. Aircraft registered with RAA. P/No: 2200. TSN: 1,600 hours. PULL-OUT SECTION Agusta Westland AW139 Pilot’s cyclic stick flight trim switch unserviceable. SDR 510013461 Pilot's cyclic stick flight trim release switch unserviceable. P/No: 92801880101. TSN: 1,206 hours/3,123 landings/32 months. Robinson R22BETA Tail rotor drive flex plate unserviceable. SDR 510013324 Tail rotor drive shaft flex plate washers debonded causing fretting to flex plate and driveshaft. P/No: A9473. TSN: 1,163 hours. SELECTED SERVICE DIFFICULTY REPORTS ... CONT. Lycoming TIO540AH1A Engine fuel pump drive failed. SDR 510013561 Engine-driven fuel pump drive failed. Investigation found pump not seized. TSN: 126 hours. Lycoming TIO540AH1A Engine fuel pump drive shaft failed. SDR 510013386 Engine-driven fuel pump drive failed. Investigation found pump not seized. P/No: 200F5002. TSN: 1,106 hours. PULL-OUT SECTION Lycoming TIO540J2BD Engine cylinder piston rings broken. SDR 510013564 LH engine No. 3 cylinder piston rings broken. Cylinder replaced due to scoring in bore. P/No: ST203P010. TSN: 1,033 hours. FSA NOV-DEC 2011 38 Lycoming TIO540J2BD Engine cylinder valve lifter seized. SDR 510013513 LH engine No. 1 and No. 3 cylinders had zero compression. No. 1 cylinder valve lifter seized. Further investigation found internal damage. Investigation continuing. TURBINE ENGINES Allison 250C20B Pc safety valve unserviceable. SDR 510013359 Pc safety valve located between compressor scroll and Pc filter failed, allowing the rear of the valve to become dislodged. P/No: 250954106. Garrett TPE33110N Engine oil scavenge pump failed. SDR 510013525 RH engine low oil pressure. Initial investigation suspected oil scavenge pump failure. Investigation continuing. TSN: 12,938 hours/10,008 cycles. TSO: 4,992 hours/3,730 cycles. GE CFM567B Engine oil scavenge line leaking. SDR 510013317 No. 1 engine aft sump scavenge line leaking. Correct tooling for repair not available on site so engine changed. P/No: CFM567B26. TSN: 18,502 hours. TSO: 18,502 hours. GE CT79B Engine chip indication. SDR 510013277 LH engine chip detector light came on at first intermittently and then continuously. Nil other indications. Investigation found chip detector contaminated with M50 bearing material. Engine removed for investigation and report. GE GE90115B Engine bleed valve door rod end bearing broken. SDR 510013283 LH engine bleed valve door rod end bearing broken. TSN: 11,705 hours/1,076 cycles. Lycoming ALF502R5 Engine failed. SDR 510013449 No. 4 engine failed. Engine suffered vibrations and fire warning with TGT rising to 1080 degrees. Engine shut down and fire bottle fired. Inspection of the exhaust found signs of molten debris and metallic sand- like debris as well as damage to the exit blades. Investigation continuing. PWA PT6A41 Engine hot section damaged. SDR 510013568 Engine hot section damaged. Found during borescope inspection. PWA PT6A114A Engine over-speed. SDR 510013275 Trend monitoring indicated engine Np over-speed beyond manufacturer's limits. Engine removed for investigation and report. Garrett TPE33114GR Engine bearing oil line worn. SDR 510013363 LH engine rear bearing oil supply line worn and leaking. P/No: 31041793. PWA PW206C Engine bearing oil tube fractured. SDR 510013354 LH engine No. 5 bearing oil pressure tube fractured and leaking. P/No: 312110901. TSN: 1,597 hours. GE CF680C2 Engine fuel pump and filter metal contamination. SDR 510013286 RH engine fuel pump and filter contaminated with metal. Investigation found a chipped edge on the pump internal carbon seal. Rolls Royce RB211524G Engine fuel nozzle feed tube cracked. SDR 510013301 No. 2 engine No. 18 fuel nozzle feed tube cracked and leaking. Investigation continuing. P/No: FK29501. GE CFM567B Cockpit fumes due to engine compressor wash. SDR 510013556 Strong oily fumes on flight deck. Investigation found No. 1 engine had a compressor wash before flight. Rolls Royce TAY65015 Engine low oil pressure. SDR 510013467 No. 1 engine low oil pressure. Investigation found high speed gearbox oil return tube chip detector and combined oil-drain tube chip detector had collected metal particles. Metal particles also found on both sides of the oil pressure filter and in the high-speed gearbox strainer. Suspect caused by failed high-speed gearbox starter idler gear. Investigation continuing. PROPELLERS Hamilton Standard 14SF23 Propeller autofeather system failed to engage. SDR 510013515 Autofeather system failed to arm. Investigation found no definitive cause for the defect. Hartzell HCC2YR1 Propeller blade damaged. SDR 510013518 Propeller blade tip separated approximately 12.7mm (0.5in) from tip. Aircraft overseas registered. P/No: HCC2YR1 COMPONENTS EAM KSE-35HC2LB Lifejacket battery deteriorated. SDR 510013548 Lifejacket battery deteriorated and showing signs of stress. Lifejacket manufactured by Eastern Aero Marine. P/No: WABH18. TSN: 22 months. Regent RSS-301 Lifejacket battery deteriorated. SDR 510012945 (photo below) Very strong chemical smell evident when lifejacket was opened to use as a training aid. Investigation found its battery had become unstable. Another three lifejackets checked - same problem found. Date of manufacture: Aug 2008. Expiry date: Nov 2018. P/No: WABH18. TSN: 40 months. Rolls Royce TAY65015 Engine fluctuates. SDR 510013279 LH engine parameters fluctuated during takeoff. Investigation found parameters fell within maintenance manual limits. Weather conditions at the time were rain and 20kt crosswinds, with a temperature of 19 degrees. TO REPORT URGENT DEFECTS CALL: 131 757 FAX: 02 6217 1920 or contact your local CASA Airworthiness Inspector [freepost] Service Difﬁculty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601 Online: www.casa.gov.au/airworth/sdr/ AIRWORTHINESS DIRECTIVES 15 - 28 July 2011 Equipment Rotorcraft Fire protection equipment Agusta AB139 and AW139 series helicopters AD/FPE/6 Amdt 7 - fire extinguishant systems. CANCELLED 2011-0140 Communications - primus epic harnesses solder splices. Inspection/replacement Eurocopter EC 225 series helicopters 2011-0136R1 Equipment and furnishings - VHF antenna for emergency flotation gear protection. Installation Oxygen systems 2011-14-08 B/E Aerospace oxygen masks - oxygen mask assemblies - broken in-line flow indicators Bombardier (Canadair) CL-600 (Challenger) series aeroplanes CF-2011-28 Oxygen supply system - deformation of pressure regulator on the oxygen cylinder and regulator assembly Bombardier (Boeing Canada/De Havilland) DHC-8 series aeroplanes CF-2011-29 Hydraulic accumulators - screw cap/end cap failure Below 5700kg 29 July - 11 August 2011 Embraer EMB-110 (Bandeirante) series aeroplanes Agusta A109 series helicopters Lycoming and Superior Air Parts piston engines 2011-0031 CN Tail rotor drive shafts. Inspection, replacement. CANCELLED 2011-15-10 This AD has been moved to the ‘fuel supply and metering equipment’ series 2011-0150 Elevator upper skin. Inspection, replacement, repair Turbine engines AD/EMB-110/8 Amdt 6 - Flap actuators Above 5700kg AD/A320/151 Keel beam side panels. CANCELLED AD/A320/154 Amdt 1 - Integrated drive generator connector. CANCELLED 2011-0134 Fuselage - Keel beam side panels. Inspection Eurocopter BK 117 series helicopters 2011-0148 Optional equipment - external rescue hoist system. Deactivation, modification 2011-0149 Electrical power - generator control unit. Identification, replacement 2011-0137 (Correction) Equipment/furnishings Passenger compartment class divider/gas spring damper. Inspection, replacement Eurocopter SA 360 and SA 365 (Dauphin) series helicopters Airbus Industrie A330 series aeroplanes 2011-0145 Time limits and maintenance checks - tail gearbox (TGB) oil level and magnetic chip detector. Inspection. Tail rotor - pitch control rod bearing. Inspection, replacement AD/A330/86 Amdt 3 - MLG bogie beam. CANCELLED 2011-0138 Navigation - Pitot probe quick-disconnect union. Torque check 2011-0139 Hydraulic power - high pressure manifold check valves. Inspection 2011-0144 Tail rotor hub Below 5700kg Airparts (NZ) Ltd. FU 24 series aeroplanes DCA/FU24/180 - Hopper lid Beechcraft 300 series aeroplanes AD/CESSNA 206/47 Amdt 3 - Rear door emergency exit 2011-15-05 FAA-approved flight manual. Correction to take-off speeds and field length Boeing 737 series aeroplanes AD/B737/201 Amdt 3 - rudder control system Cessna 206 series aeroplanes Cessna 337 series aeroplanes 2011-15-11 Installed Flint Aero Inc. wing tip tanks STC SA5090NM De Havilland DHC-1 (Chipmunk) series aeroplanes Turbomeca turbine engines - Makila series 2011-0147 Engine indicating - N2 sensor harness. Replacement Equipment Fuel supply and metering equipment 2011-15-10 AVStar Fuel Systems (AFS) fuel servo diaphragm (previously published in Lycoming and Superior piston engine series) 12 - 25 August 2011 Rotorcraft 2011-0154 Rotor flight controls - collective pitch lever restraining tab. Inspection, adjustment Kawasaki BK 117 series helicopters TCD-7916-2011 Cockpit and cabin door outside handles Below 5700kg De Havilland DHC-1 (Chipmunk) series aeroplanes AD/DHC-1/41 Amdt 1 Fuselage rear bulkhead. Inspection and modification AD/DHC-1/40 Canopy lock. Modification AD/DHC-1/43 Amdt 1 Engine primer pipe and fuel tank selector guide. Modifications, inspections and replacements 2011-14-11 No.2 and No.3 engine pylon wire bundle routing. Inspection AD/DHC-1/41 Fuselage rear bulkhead. Inspection and modification AD/DHC-1/44 Amdt 1 Mandatory modifications, inspections and replacements 2011-15-03 Sleeving and wire bundles of the fore and aft boost pumps AD/DHC-1/42 Tailplane to fuselage pickup. Modification Fairchild (Swearingen) SA226 and SA227 series aeroplanes AD/DHC-1/43 Engine primer pipe and fuel tank selector guide. Modification, inspection and replacement 2011-17-07 Primary flight control cables Boeing 747 series aeroplanes AD/B747/171 Amdt 5 - Outboard main fuel tank boost pump wiring. CANCELLED Bombardier (Canadair) CL-600 (Challenger) series aeroplanes CF-2010-35R1 Hydraulic accumulators - screw cap/ end cap failure AD/DHC-1/44 Mandatory modifications, inspections and replacements CF-2011-23 Potential damage to third crewman oxygen system Embraer EMB-110 (Bandeirante) series aeroplanes CF-2011-25, 26 and 27 Air-driven generator failure to power essential buses AD/EMB-110/13 Amdt 7 - rudder upper hinge support Bombardier (Boeing Canada/De Havilland) DHC-8 series aeroplanes Pacific Aerospace Corporation Cresco series aeroplanes DCA/CRESCO/17 Hopper lid Above 5700kg Airbus Industrie A319, A320 and A321 series aeroplanes 2010-0165-CN Oxygen system - passenger oxygen masks. Identification, modification, replacement Airbus Industrie A380 series aeroplanes 2011-0058R2 (Correction) Pneumatic - pylon bleed duct. Inspection, replacement 2011-0151 Wings - wing flap track 1 Aft Z-link (second load path) lower attachments. Inspection, repair CF-2011-20 Power lever assembly - fouling of UK CAA flight idle gate Above 5700kg CF-2011-21 Fuel system - chafing of high pressure fuel line AD/B737/164 Amdt 2 Elevator tab repair Avions de Transport Regional ATR 42 series aeroplanes AD/B737/201 Amdt 4 Rudder control system AD/ATR 42/26 Amdt 1 Cockpit forward side windows Boeing 747 and 767 series aeroplanes Bombardier (Canadair) CL-600 (Challenger) series aeroplanes CF-2011-22 Electrical - AC generator rotor band failure CF-2011-24 Wing to fuselage attachment joints - barrel nut cracking Boeing 737 series aeroplanes 2011-16-02 Boeing 747/767 equipped with CF6-80C2 or CF6-80A series engines - ice and rain protection limitations section of the Boeing 747/767 AFM 2011-16-06 Main equipment centre drip shields 39 Eurocopter SA 360 and SA 365 (Dauphin) series helicopters CF-2011-30 Cracking on the forward face of the rear pressure bulkhead web CF-2011-33 Engine support beam - cracking on the upper and lower web AIRWORTHINESS 2011-0141 Landing gear - main landing gear (MLG) bogie beam. Inspection, repair, modification Piston engines PULL-OUT SECTION Airbus Industrie A319, A320 and A321 series aeroplanes Rotorcraft AIRWORTHINESS DIRECTIVES ... CONT. Bombardier (Boeing Canada/De Havilland) DHC-8 series aeroplanes Eurocopter AS 355 (Twin Ecureuil) series helicopters 2011-0155 Time limits and maintenance checks fuel airworthiness limitations CF-2011-34 Ice protection system - failure of timer and monitor unit 2011-0164 Rotors flight control - tail rotor control stop screws 2011-0160 Equipment/furnishings - escape slide raft. Modification, replacement CF-2011-31 Incorrect heat treatment of pushrod assembly Eurocopter BK 117 series helicopters 2011-0167 Oxygen - chemical emergency oxygen containers. Identification, modification CF-2011-32 Rudder control - excessive wear on brake pedal bellcrank Fokker F100 (F28 Mk 100) series aeroplanes AD/F100/30 Amdt 1 - flight warning computer. Replacement Piston engines PULL-OUT SECTION Thielert piston engines FSA NOV-DEC 2011 40 2011-0152-E Engine - clutch assembly. Identification, replacement Turbine engines AlliedSignal (Garrett/AiResearch) turbine engines - TPE 331 series 2011-0162 Electrical power - generator relay after junction box. Modification 2011-0168 Lights - instrument lighting display brightness for flight in night vision goggle (NVG) mode. Modification Eurocopter EC 135 series helicopters 2011-0168 Lights - instrument lighting display brightness for flight in night vision goggle (NVG) mode. Modification 2011-0172 Fire protection - fire extinguishing system injection tubes. Replacement Eurocopter SA 360 and SA 365 (Dauphin) series helicopters 2011-18-51 PMA main shaft bearings AD/DAUPHIN/80 Rotor flight controls - collective pitch lever restraining tab. CANCELLED General Electric turbine engines - CF6 series Below 5700kg 2011-18-01 Fluorescent penetrant inspection (FPI) of Stage 3 low-pressure turbine (LPT) General Electric turbine engines CF34 series 2011-18-02 Replacement of fan rotor blade retainers and fan rotor spinner support 26 August - 8 September 2011 Cessna 150, F150, 152 & F152 series aeroplanes Airbus Industrie A330 series aeroplanes 2011-0170 Landing gear - main landing gear (MLG) wheel axle - reduced life limit following repair 2011-0171 Fuselage - frame (FR) 40 Fuselage skin panel junction. Inspection Boeing 737 series aeroplanes AD/B737/52 Amdt 3 - Corrosion prevention and control program (CPCP) AD/B737/152 Amdt 1 - Centre fuel tank - limitations AD/B737/198 Amdt 2 - Centre tank fuel pumps AD/B737/202 Amdt 2 - Centre fuel tank limitations Cessna 210 series aeroplanes 2011-18-03 Centre tank fuel boost pump automatic shut-off AD/CESSNA 210/36 Windshield and windows fatigue life limitation. CANCELLED TECNAM P2006T Series aeroplanes 2011-0156-e Tail rotor blades. Inspection, replacement [reduced life limitation] Above 5700kg 2011-0164 Rotors flight control - tail rotor control stop screws 2011-0166 - Doors - Main Wing Landing Gear Door (MWLGD) Rear Hinge Fitting AD/B737/347 Amdt 1 - Centre wing tank auto shut-off wiring Agusta AB139 and AW139 series helicopters Eurocopter AS 350 (Ecureuil) series helicopters 2011-0165 - Wings - Movable Flap Track Fairing Number 4 (MFTF #4) Pivot Brackets 2009-10-09 R2 Rudder limit stops 2011-0153-e Landing gear - emergency accumulator for landing gear (LG) extension. Inspection, modification, replacement Rotorcraft Airbus Industrie A380 Series aeroplanes Airbus Industrie A319, A320 and A321 series aeroplanes AD/A320/195 Amdt 1 Fuel tank safety - fuel airworthiness limitations. CANCELLED Fokker F100 (F28 Mk 100) series aeroplanes 2011-0157 Time limits/maintenance checks maintenance requirements. Implementation 2011-0159 Landing gear - main landing gear (MLG) piston 2011-0158 Fuel - fuel-balance transfer system. Deactivation AD/F100/97 Amdt 1 - State of design airworthiness directives 2010-0112R1 Oxygen system - passenger oxygen masks. Identification, modification continued from page 33 subchapter, must be designed to ensure that they perform their intended functions under any foreseeable operating condition,’ it says. Forward drain mast and ribbon heater (prior to the drain mast modiﬁcation) Source: ATSB Redundancy means different systems that do the same job, parallel systems means similar jobs being done by separate systems, and a single point failure is any part, from a nut to a software program, that could cause an entire system to fail, or indeed put the aircraft in danger. You need to keep these concepts in your mental toolkit, and apply them to every job. They are as important as calipers or sockets in a physical toolkit. As aircraft, particularly GA aircraft, age, LAMEs ﬁnd themselves having to redesign or re-create peripheral systems that were never intended to last for as long as they have. This is a mineﬁeld for engineers. Peripheral systems are not as well documented in design or manufacture as major systems, but they can signiﬁcantly affect the safety of the aircraft, as QF2 shows. In other words, ‘This goes with this goes with that,’ is more than the slogan of a fashion chain. It’s a phrase any engineer modifying a system should keep in mind as they contemplate making a change, however slight. Always consider the worst possible scenario. Part 25.1309 of the FAA design regulations for transport aircraft such as the Boeing 747 is a stringent requirement. ‘The equipment, systems, and installations whose functioning is required by this The question then arises as to whether these errors can be classed as anyone’s fault. That is a legal question, not an engineering one. Cold hard 1309 analysis before the job is always better than a hot ﬂush of doubt or guilt after it. This is meant as a cautionary tale, not a ﬁngerpointing exercise. As has been said before, pilots close the hangar doors at the end of the day. Engineering decisions, or a chain of both related and unrelated maintenance actions by various maintenance engineers can sow the seeds of destruction which, when developed, bear deadly fruit. The moral of the story is: There are some things anyone involved in aircraft maintenance or operation should forget. One of them is the saying: ‘Look after the big things and the small things will look after themselves.’ It’s just not true in aviation. If you work in design or maintenance your job is to sweat over the ﬁnest details. Welcome to the hangar. 41 AIRWORTHINESS The second point of this story is the really frightening one for engineers. Changes that breach safety can go unnoticed for years. You may have created a single point of failure – a pathogen in the system, to use James Reason’s phrase – but everything can work ﬁne for years, as long as one critical component functions. In this case it was the drain line ribbon heater – when it gave up the ghost the water backed up and found the next best way out – through the decompression panel into the main equipment bay. PULL-OUT SECTION That’s a high standard – the FAA didn’t say any reasonably foreseeable operating condition. The FAA wants design engineers to think hard about the very worst thing that could happen before they initiate a design or make a change. In other words you must follow the discipline of 1309 analysis. Hawker Pacific First CASR PART 145 PULL-OUT SECTION Hawker Pacific’s aviation maintenance and repair organisation, Hawker Pacific Airline Support Services, is the first in Australia to be approved under Part 145 of the new maintenance regulations. FSA NOV-DEC 2011 42 Director of Aviation Safety, John McCormick, presented the Part 145 approval certiﬁcate to Hawker Paciﬁc in Cairns, where they carry out maintenance of Bombardier DH-8s and Embraer 120s. He praised the organisation for the amount of work they had done to gain the approval, which followed CASA’s careful review of all their documentation, and on-site inspections. But Jim Pilkington, Hawker Paciﬁc’s Vice President Quality and Systems, was quick to explain that this ‘ﬁrst’ should not put the company on a pedestal. ‘We’re not perfect’, he says, rather describing this ongoing process as being ‘on a journey.’ Under Part 145, maintenance organisations must have a safety management system (SMS) and provide human factors (HF) training for aircraft engineers. Emphasising the ongoing process, Pilkington outlined the company’s journey. ‘It began in 2000 at Safeskies, where I was part of a panel presenting on harmonisation and the push for common regulations worldwide. Every regulator,’ he argues, ‘even though there may be minor variations, wants their maintenance organisations to carry out the work in good facilities; with competent, trained and authorised personnel, using the correct, calibrated tooling, in accordance with approved and current data.’ Hawker Paciﬁc voluntarily embarked on a process of standardising and integrating all their documentation, via an intranet, ideal for their geographically dispersed sites. In the early stages much of this documentation was in Excel spreadsheets, but the employment in 2004 of an aviation safety manager, and the purchase and setting up of a database, Pilkington says, ‘was a major factor in integrating processes. We put everything in the database – it all goes in there for trending. Holding over 40 certiﬁcates across 20 aviation authorities is a complexity which requires simplicity.’ The next step in their journey was to undergo European Aviation Safety Agency (EASA) Part 145 certiﬁcation, and following a substantial audit of their Queensland and Singapore operations by the French Direction Générale de l'Aviation Civile (DGAC) Hawker Paciﬁc became EASA Part 145 accredited in 2005. Hawker Paciﬁc’s SMS continues to evolve. ‘It’s a ﬁve-year timeline with different stages, and we’re not at the ﬁfth stage yet, where the whole process becomes generative,’ says Pilkington. Initial human factors training was conducted using an external consultant, but he adds, ‘then we brought it in house, because it has to be tailored to what you do. And there’s such a wealth of (HF) reference material out there – especially the UK CAA’s (Civil Aviation Authority’s) CAP 716 on human factors: “the bible”.’ CASA expects that by June 2013, almost 200 maintenance organisations will transition to operating under the new Part 145. The transition of RPT operators and maintainers of RPT operators will take place from 27 June 2011 to 26 June 2013. If you wish to transition your organisation, or for more information on transitioning to Parts 42 and 145 of the new maintenance regulations, please contact the Permission Application Centre (PAC) at firstname.lastname@example.org or by calling 131 757. Hallmarks of the ‘generative safety culture’ Information is actively sought Messengers are trained Responsibilities are shared Bridging is rewarded Failure causes enquiry New ideas are welcomed Safety Management and Safety Culture: The Long, Hard and Winding Road Prof. Patrick Hudson S E R V I C E S Multi-Engine Command Instrument Rating Course 4 week course - accommodation included Training on Beechcraft Baron Includes GNSS RNAV $14,525.00 - Leaders in M/E command instrument ratings. - PPL and CPL Courses - Initial issue & renewal - all grades of instructor ratings - Accommodation provided Flight Instructor Rating Course 7 week course - accommodation included Maximum 3 students per course Comprehensive resources package provided $15,500.00 43 For further information and pricing please contact us Phone: (02) 6584 0484 Email: email@example.com Web: www.johnstonaviation.com.au Cabri G2 Now available in Australia! The Cabri G2 is a brand new type of helicopter that will revolutionise the aircraft industry. Ph: 02 9708 6666 Web: www.guimbal.com.au ever had a CLOSE CALL? Write to us about an aviation incident or accident that you’ve been involved in. If we publish your story, you will receive 500 $ Write about a real-life incident that you’ve been involved in, and send it to us via email: firstname.lastname@example.org. Clearly mark your submission in the subject ﬁeld as ‘CLOSE CALL’. Articles should be between 450 and 1,400 words. If preferred, your identity will be kept conﬁdential. Please do not submit articles regarding events that are the subject of a current ofﬁcial investigation. Submissions may be edited for clarity, length and reader focus. ADVERTORIAL View our students achievements on Facebook at Johnston Aviation continued from page 29 CONCLUSIONS Two interesting conclusions arose from the study: 1. There is a much higher risk of a fatal accident resulting from manoeuvring to avoid wind turbines than by colliding with them (particularly in conditions below VMC); and 2. Collision with unmarked obstacles, either WMTs or power lines, during the conduct of aerial agricultural activities is the highest risk to aviation safety arising from wind farms. FSA NOV-DEC 2011 44 Due to this higher risk from manoeuvring to avoid turbines, it makes sense not to locate wind turbines in areas of concentrated low level air trafﬁc such as published VFR routes. The issue of stress of weather leading to ﬂight below 500ft (and potentially into conﬂict with wind turbines) should also be considered. Where air trafﬁc is likely to be funnelled through a gap or area of lower terrain due to low cloud, it should be remembered that wind turbines are usually located on the tops of hills and therefore clear of low-level escape routes. Because terrain and aircraft operations vary, it also makes sense that an independent aviation hazard/risk assessment is carried out of all proposed wind farms. This assessment should include feedback from the local ﬂying community regarding the extent of low-level ﬂying operations, and consideration of any limitations to VFR tracking in adverse weather. The potential for collision with unmarked hazards, which occurred in four of the eight cases, is clearly more problematic. It is likely that such a catastrophic collision will occur again, possibly in Australia. This study therefore recommends that: All WMTs and their supporting guy wires should be marked to enhance visibility; An online searchable database of WMTs’ location and other applicable details, preferably referenced to their geographic location, should be developed for the use of low-level aircraft operators; and Power lines located in close proximity to known areas of lowlevel aircraft operations should be marked appropriately. Some countries have already acted on this trend. Following the most recent WMT accident, the USA’s Federal Aviation Administration (FAA) formally recommended the painting of WMT as advised in Advisory Circular 74-7460-1 Obstruction Marking and Lighting. It also recommended the use of highvisibility sleeves and spherical markers on the supporting guy wires. Following the FAA’s initial response, Transport Canada released Advisory Circular 600-001 Marking of Meteorological Towers. This recommends the painting of towers and installing orange marker balls at the top of the guy wires. In the United Kingdom, recently-published Aeronautical Information Circular P021/2011 Tall Structures Promulgation and Visual Conspicuity recommends the marking and/or lighting of WMTs to safeguard aerodromes, although the marking and/ or lighting of WMTs not in the vicinity of aerodromes is not addressed. Australia has established a working group, of which CASA is a member – the National Air Space Safeguarding Advisory Group (NASAG) – bringing together all interested parties (state and territory planning and transport departments, Airservices Australia, the Department of Defence and the Australian Local Government Association [ALGA]), and chaired by the Department of Infrastructure and Transport (DoIT). This is looking at, among other airspace issues, wind turbines and wind monitoring towers. CASA has no regulatory powers regarding wind turbines or wind monitoring towers beyond a 30km radius of an aerodrome. In the absence of such regulations, CASA is trying to provide guidance to inform proponents on how best to act diligently. It is envisaged that NASAG’s role will be to provide guidance to state planning authorities, given that building regulations relating to obstructions and hazards are a state planning function. The Aerial Agricultural Association of Australia, whom NASAG is liaising with, considers wind-monitoring towers to be a signiﬁcant hazard to aerial agriculture operations. It recommends marking of wind monitoring towers and power lines, and proposes a mandatory national system of communicating the position of all wind monitoring towers and including the details on a national database accessible to low-level pilots. Defence also conducts low-level ﬂying, and since a near-miss incident involving an FA/18 and a wind monitoring mast in South Australia a couple of years ago, has a similar concern. Wind and aviation industry coordination on obstacle data has a way to go, but the RAAF is collecting data, and if a wind farm goes ahead, developers should advise the location, extent and height of the wind farm to: As a result of the research study, Aviation Projects is sponsoring a Masters project aimed at quantifying the risk in Australia of an aircraft colliding with an unmarked wind monitoring tower, and developing a prototype online database and search tool linked to a geographic reference. SUMMARY Action has commenced elsewhere to address the risks posed by wind monitoring towers, and Australia is developing a coherent strategy. Australia has a proud aerial agricultural activity and aviation safety record. Positive, coordinated and ongoing action is necessary to avoid compromising aviation safety as the wind industry’s dynamic progress accelerates. USEFUL LINKS Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA) (France) The reporting of tall structures requirement for RAAF AIS (CASA AC 139-08) is generally for approved structures, namely ‘as constructed’ information provided once built. However, for wind farms Defence has assessed, Defence also requests that developers provide wind turbine design information, not only ‘as constructed’, but also before construction to RAAF AIS. Civil Aviation Authority (CAA) (UK), Aeronautical Information Circular: P 021/2011: Tall Structures Promulgation and Visual Conspicuity Defence also requests the chance to assess all wind farm proposals, including wind-monitoring masts, at the investigation stage. Email details to the directorate of external land planning at email@example.com Transport Canada, Advisory Circular 600-001 Marking of Meteorological Towers Federal Aviation Administration (FAA) (USA), Marking Meteorological Evaluation Towers FAA, Advisory Circular 70-7460-1 Obstruction Marking and Lighting Transport Canada, Debrief: MET Towers: A collision can happen and it has happened. Australian Department of Infrastructure and Transport www.infrastructure.gov.au/aviation/ environmental/safeguarding.aspx Australia has established a working group ... the National Air Space Safeguarding Advisory Group (NASAG), looking at, among other airspace issues, wind turbines and wind monitoring towers. 45 WIND FARMS Aeronautical Data Ofﬁcer RAAF AIS (VBM-M2) Victoria Barracks St Kilda Road Southbank VIC 3006, or Email firstname.lastname@example.org Before construction proceeds, developers must also provide CASA with details of the wind farm so that CASA can issue a NOTAM advising airspace users of the construction. When construction is complete, developers must also notify CASA of the location and blade tip height in AMSL (m) of each turbine, so that a permanent NOTAM can be issued. Programmed to deceive Name withheld by request FSA NOV-DEC 2011 46 The amazing technology that directs you to wherever you want to go will just as happily direct you to where you don’t want to go, as this commercial pilot discovered The ﬂight started as a routine transit from Coober Pedy to Port Augusta in South Australia. I had planned via the standard IFR route to the west of Woomera’s restricted areas that had been active earlier that day, and all was well with the aircraft as I departed Coober Pedy and called Melbourne Centre with my estimates. I was advised that Woomera had ceased operations for the day, and a direct route would be available to Port Augusta, (YPAG). This I happily accepted, as it would save about 10 minutes of ﬂight time and fuel. Since I was ﬂying a pressurised turboprop, the saving was worth considering. The clearance was issued, I made the track adjustment, climbed to 27,000 feet and settled in for the one-hour trip. My aircraft was equipped with an IFR GPS, as well as a separate moving map with its own GPS database. Although independent systems, they talk to each other, and the moving map displays ﬁxes and tracks from the other unit. All was well, and the weather was perfect up there, as it generally is above the clouds. We were in bright sunshine, with everything going to plan and an early return home expected because my passengers had ﬁnished their business early. I even noticed that the GPS was indicating we were making very good time and had a good tailwind. I couldn’t have been happier. Top of descent arrived, and I called Melbourne Centre to obtain clearance and trafﬁc, and started down. By this time, the cloud below had built to a solid layer with the tops around 18,000ft, but this was not unusual for the time of year, and I had ascertained that Port Augusta was clear, expecting a simple visual arrival. As we popped out of cloud at 12,000ft, I was surprised to note that the terrain looked unlike what I had been expecting for this stage of the ﬂight. We were over a large salt lake that should have been some miles behind us, and I couldn’t see the top of Spencer Gulf, as I would have expected to from that height. I suddenly realised that I wasn’t where I thought I was, and I was getting there at nearly 300kt! I stopped the descent and started a troubleshooting cycle to see where I was, and why I was there. Part of my cycle included zooming in on the moving map to see what it had to say. In fact it told me a couple of things. Firstly, it showed the aircraft to be over the southern end of Lake Torrens but, more interestingly, it showed a waypoint for the Port Augusta airport to be there as well! That of course couldn’t be accurate, so the error had to be related to the GPS programming. I didn’t have time to delve any further into the GPS at that stage, because we were still some distance from Port Augusta, and I busied myself with setting up the ADF to track to the aid, making certain I could stay visual for the remainder of the trip, and amending my ETA with Melbourne Centre. The rest of the trip went without incident, but after landing I had to get to the bottom of my GPS error. 47 With this particular GPS unit, there were a large number of waypoints preprogrammed into the certiﬁed database, and updated from time to time by the manufacturer. There were also user waypoints that could be set by the pilot. These took the form of Lat/Long, Brg/Dist, or Rad/Dist, depending on how you wanted to set it up. It became evident that at some point previously a pilot had entered a waypoint into the GPS, some 56nm to the north of Port Augusta, based on the Leigh Creek VOR, and called it YPAG! This was signiﬁcant for a couple of reasons. Firstly, you should never use a name that indicates the airport position in this manner as it can be confused with the standard identiﬁers. Secondly, when this is done, it overrides the GPS programming, and the unit then displays this new ‘user waypoint’ whenever the airport is selected on the GPS. Lastly, if you set up a user waypoint in a GPS, and you are not the only pilot of that aircraft, you should have some kind of naming convention, or you should delete the waypoint after you’ve used it so as not to confuse anybody else, or have numerous similar waypoints in the system with different names. Now that I had discovered the error in the GPS, I had to work out why it had caused my difﬁculty. That was actually the easy part. As I departed Coober Pedy and obtained a direct clearance, I had inadvertently set the GPS up to use the airport waypoint instead of the NDB. This, I can only rationalise, was because I so often go to airﬁelds that have no aid, and therefore are entered into the GPS with the four letter identiﬁer. In reality, it shouldn’t have made any signiﬁcant difference, as the Port Augusta NDB is located very close to the airport, but the procedure is valid and in place nevertheless. Secondly, while I normally would do a conﬁdence check by comparing my ﬂight plan distances, bearings and times with the GPS data I had just entered, this check wasn’t available once I had selected ‘direct to’. My ﬂight plan was of little assistance to conﬁrm the new data. In fact, only the distance to go would have been obviously different anyway, as the new waypoint was almost on the direct track. Combined with the strong tailwind, the shorter distance gave me a very good time interval, but instead of simply accepting it, I should have investigated further. I should also have zoomed in on the moving map much earlier, when I would have been able to see the variation in waypoint locations. It was a timely reminder that when relying on the GPS for remote area navigation, you should also check with other sources of information and not simply accept that the GPS data is correct. Normally it will be, but every now and then, it will surprise you. I’m just thankful that this occurred in daytime and good weather. I can live with the embarrassment, but the situation could have been very different at night or in bad weather! CLOSE CALLS Firstly, I checked the accuracy of the current GPS position against the ADF indication and the airport chart. All looked as it should. This was getting frustrating. Then, I entered the airport reference on the GPS, and was shocked to ﬁnd that it was 56nm away! I had found the error , but why was the GPS telling me this? It turned out to be a very simple solution. He who rides a Tiger Name and address withheld by request FSA NOV-DEC 2011 48 Too much conﬁdence and not enough anticipation gave a normally thoughtful young pilot a memorable fright At the beginning of 2005 I was fortunate enough to land my ﬁrst ﬂying job at a small aerodrome located near Melbourne. I was 22 at the time and, like most young pilots fresh out of university, was willing to take a job anywhere, anytime and for next to nothing. Fortunately this was a full-time position which paid more than the award for a junior grade 3 ﬂight instructor, in addition to being located not too far from my home town. My duties involved both ﬂight and ground instruction through the ﬂying school’s AOC, and private and charter ﬂights through the charter company’s AOC to and from such places as Flinders Island, northern Tasmania and Phillip Island. One of the best parts of the job was the unusually high number of aircraft types available to use for both ﬂight training and charters. My favourite was the DH82 Tiger Moth. At the time we had two well-maintained Tigers, as well as an AgCat. It wasn’t too long before I had my chance to ﬂy the Tiger and I took it with open arms. Before I knew it I had over 100 hours on the aircraft, which may not sound like much but when you consider that the average joy ﬂight lasted for approximately 20 minutes, the number of take-offs and landings quickly added up. This story relates to one particular ﬂight I undertook in the Tiger on Anzac Day 2005. I was to ﬂy in the left echelon position behind an experienced agricultural pilot in the AgCat and to the left of the second (slightly betterperforming) Tiger, being ﬂown by a very experienced and well-respected colleague who had previously trained me on the Tiger. I had a small amount of formation experience after having been signed off a few weeks earlier and felt comfortable about participating in the display with the time I had on the Tiger. We had brieﬂy discussed the ﬂight over coffee during the morning and I had been given permission to carry one of my students in the front seat. As we lined up I took a moment to reﬂect on how lucky I had been to snag this as my ﬁrst job, as I knew I’d be able to look back on ﬂights like this and smile. The time had arrived to begin our take-off roll and perform our display over the nearby town of Cranbourne before the arrival of the Roulettes who would do a low pass en route to the Shrine of Remembrance. As the lead aircraft began to roll I carefully introduced power to roll in unison with the Tiger to my right. As we approached our rotate speed I began to get that feeling in the bottom of my gut that something wasn’t right, and in a matter of seconds I found out why. Before lining up I had noted the direction of the wind, which was to be at our two o’clock position during the take-off roll. I put it down to my lack of experience in formation ﬂying that I failed to realise that being in the position I was, the wash from the two-metre wide propeller on the AgCat was going to drift across directly in front of All I could do was try not to over control the aircraft by resisting the temptation to pull further back on the stick, and hopefully ride it out. the track I was to be taking. This, combined with the fact that I was trying to keep up with the slightly betterperforming Tiger Moth on my right by rotating slightly earlier than I usually would was going to mean I’d have to ﬁght to keep control of the aircraft during ﬂight at such low IAS. Sure enough, as we slowly became airborne I could feel the aircraft yawing and rolling toward the left, bringing us dangerously close to the aircraft parked alongside the runway. I had full right stick and a small amount of right rudder depressed in an effort to regain control. The problem was that the Tiger Moth was only designed with ailerons on the lower wings, greatly reducing the rollrate available. After having caught up with the guys afterwards, I realised they had no idea how close I had come to disaster, and I’m sure what I remember about the event has somewhat been slightly overdramatised. However, I have learnt many valuable lessons from it. If I were to offer any advice to anyone, it would be to those fellow aviators who are currently trekking, and those who are yet to trek, down the all-too-familiar path of gaining their hours as quickly as possible in order to reach their goal of perhaps ﬂying a commercial jet aircraft. I’m sure that there will be a stage during the early years of your career at which you become so conﬁdent in your ability to ﬂy an aircraft that you will forget, if only momentarily, how quickly things can become pear-shaped. I hate to say it but I was probably too conﬁdent in my somewhat, limited ﬂying ability and I almost paid the ultimate price. Please be careful not to make the same mistake, whether you’re conducting circuits in a Cessna 172 as a Grade 1 META Instructor or ferrying an empty Piper Chieftain from Bathurst Island to Darwin. Good luck and happy ﬂying. 49 CLOSE CALLS All I could do was try not to over control the aircraft by resisting the temptation to pull further back on the stick, and hopefully ride it out. And ride it out we did! Within seconds, but after what felt like an eternity, the aircraft began to climb and roll to the right. I regained my composure and, shortly after, joined up with the group. I’m glad to say the remainder of the ﬂight was a complete success and I enjoyed myself immensely. Sure enough, this will be the time at which you will ﬁnd yourself in trouble and hoping against hope you can rectify the situation ASAP. I was fortunate to have resisted the temptation to over-control the aircraft in an attempt to correct the situation. Almost pressing the grapes! Bruce Campbell A nighttime simulated engine failure could easily have added human claret to the wine. FSA NOV-DEC 2011 50 Looking back on my time as an instructor I can honestly say that I enjoyed (almost) every minute of the flying. There were times, though, when I had to think quickly, work hard, and use all my resources to keep our aircraft flying, or get it back on the ground safely. These experiences included a real engine failure (single engine) on take-off from Archerfield, when the Restricted PPL on an under-supervision navex just froze and kept the aircraft in the climb attitude. I had been apparently uninterested in his procedures, but was observing him closely in the side-window reflection of the C172. I literally shoved the nose down and selected full flap – we were at about 100ft AGL. We touched down on the far piano keys and managed to skid to a stop just short of the boundary fence. Problem? Stuck valves and bent pushrods. Another incident was another real engine failure in the circuit. I just happened to be on a close downwind leg and landed safely across the field in the general grass area, carefully avoiding cones and gable markers. This time it was a cracked cylinder, about 2cm from the crankcase. The crack extended around three quarters of the cylinder and a couple more seconds of operation would have seen a catastrophic separation. Yet another was an aileron control malfunction (on a Beech 23) in the training area at around 4000ft. The aircraft suddenly rolled to the right and it required nearly full continuous opposite aileron application to keep the wings level. We landed safely. Cause? Half the aileron’s self-centring device was broken, hence full inadvertent roll the other way. There were many other very tense moments with aircraft problems, but none of them related to maintenance issues. But the real humdinger of a close call occurred just before I gained my CPL. I was undertaking fulltime training at Cessnock in the late 1960s, having completed my PPL and some part-time training towards CPL at Archerfield. My licence was already endorsed with CSU/retractable, so most of my training at Cessnock was on a Piper Arrow PA28-R. Cessnock aerodrome was then, and still is, in the middle of the Hunter Valley wine district. Grapes were grown immediately to the east of the field boundary, between there and the main road. I’ve had to consult my first logbook to clarify dates and flying sequences/hours immediately preceding this close call. The sequence, I believe, is important, and probably has some relevance to what happened. The CPL training, including NVMC, was proceeding apace daily, and nightly, and was in the final polishing stages. On the previous day I had flown for 7 hours 40 minutes, comprising separate day and NVMC navs and night aids work on a third sortie, all pilot-in-command - under supervision (PICUS). It was approaching first light when I finally hit the sack exhausted! Someone woke me later, and when I asked the time, I was told it was early afternoon. Another two training sessions in the Arrow followed, the second late in the afternoon, followed by a night navaids period, (again PICUS), around Maitland some hours after tea. We returned to base on an outbound track from Maitland. Overhead Cessnock at 1710ft on AQNH (Cessnock elevation 211ft), we commenced a right turn to let down for a right-hand circuit on runway 36, (required because of high terrain to the west). The oil-pot flares for runway lighting were still OK, only one or two out but not the threshold ones, and radio calls had confirmed no other traffic in the circuit. Only the altimeter, used correctly, can provide the ultimate guide to glide path relative to a fixed illuminated point, such as threshold lights. 51 All was normal. Checks were completed quickly, and I concentrated on the approach, using the flare path as my primary visual cue. I remember cutting the corner on base leg, and starting to turn final quite close in. I can still see it in my mind’s eye. The wings were not quite level and we weren’t lined up when the engine gave a tremendous roar, spluttered and caught. My right hand had firewalled the throttle too quickly, and the instructor’s left hand was on top of mine! In the split second this happened, we had both woken up to the altimeter reading 360ft. Not lined up, and no, we didn’t have 360ft to descend. We had both been briefly lulled into thinking that ground level was at zero feet. Somehow we clawed our way back to an acceptable climb speed, to the right of and parallel to the runway, (over the grapes, remember, and I recall seeing the needle under 300ft), cleaned up the aircraft, and completed a normal circuit and landing. I don’t recall much of a de-brief from the instructor, if at all. We had almost made bloodied wine. From memory, I don’t think the incident was mentioned to the CFI, and was just passed off as one of those things that happen in training. I certainly didn’t want to cop any flack at this stage. I was too busy to reflect on it in the coming days; my flight test was scheduled for later in the week. It wasn’t until some ten years later, when, as a senior instructor and CFI teaching NVMC, that I thought seriously about this particular close call. Daytime simulated forced landings are a breeze – you can see the ground and judge height. But at night it’s oh so different. You have considerably fewer visual cues, even in the circuit with a flarepath to guide you. Only the altimeter, used correctly, can provide the ultimate guide to glide path relative to a fixed illuminated point, such as threshold lights. Undoubtedly, the primary contributing factor in this incident was misreading the altimeter relative to circuit heights (being lined up by 500 AGL on final), but over-work and tiredness contributed immensely to this predicament. I have been ever mindful to remind my students constantly about these points. It has taken me nearly thirty years to decide to put pen to paper about this incident, after reading about many others in the ‘crash comic’. There were many incidents, of varying degrees of danger, during my time in the left and right-hand seats, but none ever quite like this. CLOSE CALLS Right at this point, my instructor, only a few years my senior, (he was probably just shy of thirty), pulled the power and nonchalantly said, ‘Engine failure’. I immediately requested that he hold the gear override lever up to stop the warning horn continuously blaring, and I commenced a glide approach, electing not to select gear down until I was sure of making it. ;OL(\Z[YHSPHU Themes from ATSB investigations— what’s worrying us I recently had the pleasure of meeting with my regional aviation colleagues at the RAAA convention in Coolum, Queensland. The convention was a great opportunity to catch up 52 with the many dedicated people involved in regional FSA NOV-DEC 2011 aviation. I was also reminded of the vital role regional aviation plays in keeping Australia safely connected. During the convention, I discussed the major ﬁndings emerging from our investigations into aviation accidents and incidents. Some of these ﬁndings are starting to form patterns or themes of aviation safety concerns and are worth sharing with you here. They include: s Issues with some elements of pilot training— particularly for regular passenger transport pilots in the handling of standard but rarely performed procedures. s Problems with stabilised approaches—both in establishing the elements of a stable approach and in decision-making about whether to proceed with a landing. s Inadequate fuel management—mainly in flight planning, checking and monitoring for general aviation pilots (we’ll be picking up this issue in one of our ‘avoidable accidents’ series). We’ll be keeping a close eye on emerging safety concerns and others as they begin to form and will keep you informed of any developments. In the meantime, don’t forget to follow us on Twitter (@ATSBinfo) to ensure you’re kept up to date with our investigations and safety advice. Turramurra investigation explores multiple factors M ost people think there is only one major cause to an accident,’ explains Nev Blyth, the ATSB’s Manager of Technical Analysis. ‘Most of the time though, these events are extremely complex, with multiple factors combining in sometimes unforeseen ways.’ As a result, accident investigations must painstakingly examine all elements of the occurrence. An example of this holistic approach is the ongoing investigation into the fatal helicopter accident near 22 July 2011, claimed the lives of two people when a Bell 206L helicopter collided with terrain. ATSB Investigators are analysing numerous possibilities to unravel what ultimately led to the accident, and gain as complete an understanding as possible. To begin with, analysis of the wreckage distribution and key components has indicated that a section of the helicopter’s tail preliminary indications of failures or pre-existing conditions that could have brought about the tail boom strikes. Meanwhile, ATSB investigators are analysing weather forecasts and local observations to develop an appreciation of the local conditions and the variability of the weather around the time of the accident. Witnesses reported low cloud and rain showers in the area. surveillance records and recordings of radio communications between to obtain information from recovered on-board GPS navigation equipment. Although seriously damaged in the accident, the equipment may provide additional and potentially valuable detail on Finally, investigators are conducting interviews with witnesses to human factors investigator has been assigned to the team. Findings from all these avenues of inquiry will be combined in the the accident as possible. Martt in Dolan Martin Chief Commissioner May 2012. Q (]PH[PVU:HML[`0U]LZ[PNH[VY Lake Eyre investigation yields a preliminary report T he ATSB has released its preliminary report into the fatal helicopter accident which occurred near Lake Eyre in South Australia. On 18 August 2011 the pilot and two passengers of the aero helicopter were television documentary. At about 5.15 pm, the helicopter landed on an island in the Cooper Creek inlet, about 145 km north of Marree, so that they could meet and interview a tour group. an investigation. A team of four was convened in Adelaide, with investigators Mechanical Engineers (LAMEs), an electronics specialist, and a generalist investigator. From Adelaide, they travelled to Marree, which would form the base of operations. thing that had no interest in giving any shade.’ Nevertheless, the investigators were fortunate with the weather. especially if they’ve been burned. To protect themselves, the investigators wore ‘bio-suits’ – blue plastic suits that are disposable. When working in the heat, the suits can make an uncomfortable day almost unbearable. Other equipment included basic toolkits for the two LAMEs, as information on CD that the manufacturers had provided. well before 7.00pm, when the helicopter departed the island. group advised authorities of what they had seen and initiated a search. Later that night, they located the helicopter, about 3 km from the departure point. A trail of wreckage 60 metres long stretched out. and two passengers died in the accident. sharing updates with the headquarters in Canberra, as well as making arrangements site,’ recalls Rob Chopin, ATSB Senior Transport Safety Investigator. ‘Basically, the only way in and out of the site was by helicopter.’ During the on-site phase of the investigation, the team would make four return helicopter trips to the site, about 3 km from the Cooper Creek Inlet. An undulating landscape, consisting of sand dunes and low scrub, the site itself presented its own challenges. two engines the engines would need to be examined under the supervision of ATSB investigators, along with various other components including the GPS, which had been damaged by the impact. Using these recovered materials, the observations gathered at the site, and the input from witnesses and background research, the investigators will work to 12 months. ‘We took enough materials to make a was 500 metres away, and was a thorny is available on the ATSB website www.atsb.gov.au Q ATSB ‘Communications was our biggest problem,’ explains Chopin. ‘Marree itself did not have mobile coverage, so all of our connections had to be made via satellite intending to return to their accommodation at a property about 48 km north of Marree. One witness overheard the occupants discuss the option of looking at the lake when airborne. A number of witnesses from the tour group saw Photo of accident site the helicopter depart in an easterly direction before turning to the north. Several also reported seeing the helicopter descend before going out 53 The ATSB is seeking your views on Conﬁdential Reporting O ne of the main beliefs of the ATSB is that it is more important to pursue safety outcomes than their feedback on the scheme, and what changes, if any, they would like to see your comments to help us have the best scheme in place. We are particularly interested in any concerns you have about the proposed reforms—whether you agree with the new regulations or would like to see more changes.’ principles are embodied in the legislation that underpins the ATSB’s investigation role: the Transport Safety Investigation Act 2003. While organisations within the transport industry should provide their employees with the opportunity to report their concerns without fear of any reprisal, some may not, or may not do so 54 relevant documents and contact details can be found on the News area of the ATSB website at www.atsb.gov.au. Any comments need to be submitted by 16 December 2011. safety concern goes unreported, the ATSB by the ATSB are important because they FSA NOV-DEC 2011 All parties are given an opportunity to provide comment on responses. (REPCON) scheme enables any person to report an aviation safety concern to the ATSB. Steve Young, Manager of ‘completed’ with all personal details permanently removed from the REPCON at the ATSB says: ‘A “reportable safety REPCON brief in Flight Safety Australia. Now, however, the REPCON scheme is reportable under the mandatory reporting issues such as organisational matters, poor or inadequate procedures relating to training, maintenance, rostering, etc.’ to the appropriate organisations in order to highlight safety issues that might otherwise remain unreported. Protection of the reporter’s identity, and any person named in the report, is a core element of the scheme. A report must contain the reporter’s contact details before it will be accepted as a REPCON. Key dates to remember maritime schemes are being consolidated while including a scheme for rail for the The scheme provides de-identiﬁed reports to the appropriate organisations in order to highlight safety issues that might otherwise remain unreported. Reportable Safety Concerns that meet established under the Transport Safety Act 2003,’ explains John Taylor, Principal Lawyer at the ATSB and manager of the REPCON reform project. ‘As a result, by removing all personal references and reporting will be “Restricted Information” can proceed further. Once authorised, have the same substantial protections as information that is generated or obtained through our safety investigations. responsible organisation for action as deemed appropriate. CASA will comment on any action taken by the organisation. transport safety without fear of reprisal or sanction. Some of the matters reported are considered serious issues, and some may be less so. But all reports are assessed and handled sensitively, because the ATSB would far prefer to prevent an accident than have to investigate one. Q opportunity for stakeholders to give The consultation on the draft regulations for conﬁdential reporting closes on 16 December 2011. The ATSB plans to hold a second round of consultation with stakeholders in early 2012. The ATSB plans for the new Regulations to take effect in 2013. More information If you have any questions about the new conﬁdential reporting reforms, email email@example.com or call John Taylor on 02 6274 6416. Providing comments To provide comments on the proposed Regulations, we recommend you ﬁrst read the Conﬁdential Reporting Discussion Paper and Explanatory Statement. These are available from the News area of the ATSB website www.atsb.gov.au. Those documents help explain the proposed regulations. You can submit your comments by email to firstname.lastname@example.org Investigation briefs Emergency location issues divers found that, as a result of the impact Investigation AO-2011-055 accident. An accident involving an R44 helicopter, and the issues surrounding the subsequent search and rescue, have prompted warnings about the importance of programming and testing emergency locator transmitters. When installed, an ELT must have been programmed with a unique into three separate pieces. ELTs need to be registered with the Australian Maritime Safety Authority (AMSA), so that AMSA’s RCC can the northern shore of the lake. Neither On 30 April 2011, the owner–pilot of the helicopter was conducting a local Kilmore Gap, Victoria. During low-level manoeuvring at low speed around a dam, the pilot lost directional control and was seriously damaged; the pilot and passenger sustained minor injuries. accident. can be directly programmed before a programming dongle in the wiring that in this occurrence the ELT had been inadvertently reprogrammed with incorrect information from the dongle. In response, CASA published Airworthiness Bulletin 25-018 to alert maintenance organisations to the risk of programming dongles transferring potentially invalid details to the memory low that the wingtip contacted the surface of the water could not be established unlikely that the pilot deliberately ditched 55 any initiating cause. Regardless of the reason for being at low level, it is probable that the pilot misjudged the height of the distracted at a height from which the pilot impacting the water. activated the emergency locator transmitter (ELT), which broadcasted ‘a cry for help’ on the 121.5 MHz and 406 MHz frequencies. However, the 406 MHz transmission that was monitored by the search and rescue (SAR) agency did not The dangers of low-ﬂying information. As a result, there was no On the morning of 21 June 2010, the owner–pilot of a Cessna 172N, registered VH-UFN, departed from a private airstrip near Woolcunda Lake, New South Wales transmission on 121.5 MHz , but as it turned out, the satellite system used by the rescue coordination centre (RCC) had not been receiving alerts on that frequency since February 2009. Fortunately, pilots of a number of Investigation AO-2010-045 A fatal accident at Woolcunda Lake has served as a tragic reminder of the heightened risk that surrounds low-level operations. organisational or systemic issues that aviation operations. However, the accident does provide a timely reminder of the heightened risk associated with low-level operations, especially over expanses of report AR-2009-041 Avoidable Accidents addresses the reported missing to authorities. transmission during routine monitoring, emergency locator beacon (ELB) and a SPOT Satellite Messenger (SPOT), but which mobilised the crew of a search and on the 121.5 MHz signal, and arrived at ATSB advised that they were introducing measures to increase awareness of programming dongles in their new helicopters. Q located in Woolcunda Lake, in deep water towards the centreline of the lake. Police and in particular, the reduced time available to recover from any loss of free on the ATSB website www.atsb.gov.au Q Bad procedures top aviation safety concerns P continue to pose the biggest risk to aviation safety, according to a new ATSB research report. Why procedures matter Case study 1: Emergency checklist Investigation AO-2008-003 investigations conducted by the ATSB in 2010–11. (Safety issues are factors that operations). Overwhelmingly, the majority of safety issues related to poor or inadequate 56 by operators of high capacity and other passenger operations, covering a wide range and variation of procedures. On descent to Bangkok International Airport, a Boeing 747 experienced a substantial water leak in the forward galley. The cockpit indications progressively showed a number of electrical power-related malfunctions. Many of the aircraft’s communication, navigation, monitoring and flight guidance systems were affected. The aircraft eventually landed safely at Bangkok Airport. One of the major findings of the investigation reveals that the operator’s Quick Reference Handbook for flight crew did not include sufficient information for flight crew to manage an electrical system emergency. This lack of procedural information resulted in the flight crew relying on their recollection of systems knowledge to assess and manage numerous failures with a limited amount of time available before the batteries were depleted. The investigation concluded that a checklist would have increased the consistency of crew actions in such emergencies. FSA NOV-DEC 2011 ATSB Chief Commissioner, Mr Martin Dolan, said this is an alarming result the top aviation safety risk in last year’s report. inadequate aviation procedures accounted safety,’ Mr Dolan says. ‘I remind operators that good standard operating procedures remain one of the best defences against aviation accidents.’ Main equipment centre Example corrosion on the GCU 3 circuit board (arrowed) Case study 2: Hover height Investigation AO-2009-068 pilots are very reliant on adequate and accessible procedures to ensure they can issues that can arise during operation.’ Safety issues and safety actions is available on the Safety Awareness area of the ATSB website at www.atsb.gov.au. Q During a rescue operation, a Bell helicopter 412 approached the winching area of a ship while lowering a rescue crew member and paramedic. When the pilot lost sight of the ship’s landing area the helicopter began to drift and the pilot was unable to stop the helicopter’s movement. The winch cable separated from the helicopter resulting in the rescue officer and the paramedic falling 10 metres to the ship’s deck. Both were seriously injured. The investigation found that the operator’s winching procedure did not require the pilot to confirm an adequate hover reference before deploying personnel on the winch. REPCON briefs Australia’s voluntary conﬁdential aviation reporting scheme REPCON allows any person who has an aviation safety concern to report it to the ATSB confidentially. All personal information regarding any individual (either the reporter or any person referred to in the report) remains strictly confidential, unless permission is given by the subject of the information. The goals of the scheme are to increase awareness of safety issues and to encourage safety action by those best placed to respond to safety concerns. REPCON would like to hear from you if you have experienced a ‘close call’ and think others may benefit from the lessons you have learnt. These reports can serve as a powerful reminder that, despite the best of intentions, well-trained people are still capable of making mistakes. The stories arising from these reports may serve to reinforce the message that we must remain vigilant to ensure the ongoing safety of ourselves and others. Gable markers Report narrative: that aerodrome gable markers used at the aerodrome on certain taxiways are not taxiway markers, but aerodrome gable markers, and as such, do not conform to standard taxiway marker requirements. with unserviceability markers 4 weeks ago to note that the area is no longer suitable conducted October 2009 noted that Taxiways B and D have a width of minimum taxiway width of 10.5 metres Response/s received: REPCON supplied the operator with the their response: an organisational culture which is and procedures in place are integrated into day to day business and followed by the just culture philosophy is integrated as an organisational norm. All safety reports are analysed, risk rated and actioned as appropriate on a 57 through procedural documentation and also informally through various safety communication mechanisms. REPCON supplied CASA with the provide the required lateral taxiway clearances, and may result in an incident. clearance requirements were not being requirements. Again, gable markers have been used immediately adjacent to the sealed area of the taxiway. It is reported that an ex-CASA aerodrome inspector has surveyed the area in CASA has since reviewed this matter. REPCON supplied CASA with the de- the penalties for reporting safety issues CASA is unable to address these concerns. their response: implement a CASA approved safety management system (SMS) which includes safety reporting processes. During recent surveillance conducted on the operator’s SMS we found no evidence that supports neglect in encouraging safety reporting and in taking action on reported discrepancies to satisfy regulatory obligations. have been removed and the “Parking Clearance” line in between taxiways B3 and D2 have been obscured with black paint so as to provide the appropriate taxiway strip width for a code B taxiway. CASA on this matter. standards have not been met. Safety management system Safety reporting is a fundamental Response/s received: REPCON supplied the operator with the Report narrative: and airline employees are obligated to utilise the safety reporting procedures within the SMS and by the operator’s administration manuals. their response received: With reference to this report please be aware of the following points: Taxiway B2 and D2 did have yellow gables taxiing on D2 that there was a corner that the operator’s pilots are losing faith with the company’s safety management instances where pilots had been reportedly penalised for reporting safety reporter is also concerned by the lack of action or basic follow up on safety reports. How can I report to REPCON? Online: www.atsb.gov.au/voluntary.aspx Telephone: 1800 020 505 Email: email@example.com Facsimile: 02 6274 6461 Mail: Freepost 600 PO Box 600, Civic Square ACT 2608 ATSB between taxiways B2 and D2 was believed to be narrower than the required standard. It is also believed that the gable markers that are placed on either side of this taxiway do not meet the standard taxiway marker requirements, their response: The final piece of the puzzle FSA NOV-DEC 2011 58 Fifty years ago, a dramatic and puzzling Australian airline accident led to the introduction of what could be described as the final ‘jigsaw piece’ in the evolution of our safe airways system. Other ‘pieces’ essential to all-weather flying— aviation meteorological services, air traffic control, radio communications and radio navigation aids allowing aircraft to navigate accurately in cloud—had been progressively set in place over the past 30 years. But one vital lesson remained, as Macarthur Job writes. Top to bottom: s$ISINTEGRATEDWRECKAGEOF6(46#RAISEDFROMTHEBEDOF Botany Bay by Navy divers working from HMAS Kimbla. s4HEFRAGMENTEDWRECKAGEBEINGSYSTEMATICALLYLAIDOUTON the ﬂoor of the Department of Civil Aviation's hangar at Sydney Airport during the investigation. s$AMAGEINCURREDATTHEINBOARDENDOFTHESTARBOARDOUTER wing as aerodynamic forces tore it away from the aircraft. The Ansett-ANA Viscount 720, VH-TVC, photographed at Melbourne’s Essendon Airport ﬁve months before its fateful last ﬂight. An eerie premonition Ansett-ANA’s s flight schedule on Thursday, 30 November 1961 for VH-TVC, one of its state-of-the-art turboprop Vickers Viscount 720s, was surprisingly light—only three trips between Sydney and Canberra—the relatively short distance of 130 nautical miles. The day return trip to Canberra, though rough, was without incident, and TVC landed back at Sydney Airport just on 6.45pm. The crew rostered for the 7.10pm flight back to Canberra, where the Viscount would remain overnight, comprised Captain S.A. Lindsay, First Officer B.A. Costello, and flight attendants Aileen Keldie and Elizabeth Hardy. On her way to the canteen for her evening meal before boarding TVC, Hardy commented to another flight attendant on the ‘terrible weather’, saying she was glad she was ‘going on a Viscount tonight’. Tongue-in-cheek, she remarked: ‘I think I’ll ring Canberra and tell them we aren’t coming’. At around 6pm, Captain Lindsay went to the airport briefing office. The meteorological officer gave him the route forecast and briefed him on the active front approaching Sydney from the west. Radar returns showed cloud tops extending to 35,000ft, and pilots were reporting exceptionally severe turbulence. Wild weather ‘Don’t be silly,’ Schmidt retorted with a laugh, ‘off you go.’ But as the two flight attendants moved to the door, Hardy called back: ‘Now don’t forget. If something does happen, tell Helen and my mother.’ The cabin was configured for 48 passengers, but only 11 were booked on the flight. All but two were Canberra residents—a gynaecologist at the Royal Canberra Hospital, two civil servants, an army major, three Canberra company managers, the wife of another Canberra medical practitioner, and a self-employed businessman. The other two were an oil company representative who had been attending a conference, and a soldier on his way to the Royal Military College. Cleared for take-off At 7.05pm Costello called Sydney tower for a start-up clearance. Five minutes later, the tower cleared TVC to runway 25 for take-off into the southwest. Because of the heavy cloud and rain, the taxiway and runway lights were already on, and the tower issued the Viscount with an amended airways clearance. To avoid inbound traffic, this required a departure track of 244 oM until 37nm DME from Sydney, and thence to Canberra, cruising at flight level 160 (16,000 feet). At 7.16pm the controller cleared TVC for take-off, instructing the crew to maintain runway heading to 3000ft, then to turn left to pass ‘over the field, not below 5000ft’. The aircraft took off normally, its navigation lights being lost to view as it entered heavy cloud at about 800ft. The controller logged the time as 0917 GMT, 7.17pm local. Communication lost When Lindsay returned to the terminal, the two flight attendants were waiting to board VH-TVC. The Viscount was parked on the rain swept tarmac just outside, and Costello, sheltering under an umbrella, was making a pre-flight inspection with a dispatching engineer. Five minutes later, the controller offered the aircraft a choice of two departure tracks; the original track Lindsay had nominated, or a 217o track that would avoid an extensive storm cell. Costello’s voice came back, ‘Thank you, we’ll take the 217.’ The controller instructed the aircraft to ‘report setting course’. The two women were joined for a moment by flight attendant Dagmar Schmidt, another trainee. She had been a member of the Viscount’s crew on the late afternoon flight from Canberra. Hardy asked what the trip had been like. ‘Extremely rough,’ Schmidt told her. ‘The worst I’ve experienced.’ Concerned, Hardy replied, ‘I’ve got a feeling The aircraft did not call as expected, and at 7.25pm the controller transmitted: ‘Tango Victor Charlie, have you set course yet?’ There was no reply. Further calls also failed to elicit a response, so the controller, believing the aircraft had suffered a radio failure, contacted the senior controller to introduce the uncertainty phase of search and rescue. 59 PIECE OF THE PUZZLE It had been a wild day in Sydney, with heavy rain, blustery westerly winds, thunder and lightning. Conditions seemed to be worsening, and Hardy, only three weeks with the airline and still under training, felt nervous. Her attitude was not helped by the vivid dream Keldie had recounted a few days before. In the dream, they were the only cabin occupants of a Fokker Friendship that crashed on landing and, as they left the wrecked aircraft, they saw one of the pilots slumped over the controls, apparently dead. They had joked about it; nevertheless they found it disturbing. something’s going to happen tonight.’ As she picked up her bag she added: ‘If anything should happen tonight, will you tell my sister and my mother?’ But when no sign of the Viscount could be detected on radar, this was upgraded to the alert phase. The situation was reported to the police, the RAAF, the RAN and the Volunteer Coastal Patrol. Coastal shipping was alerted, and an air-sea rescue launch set out to sweep of the foreshores of Sydney’s Botany Bay. It was still possible the Viscount was continuing in accordance with its flight plan, and in the absence of any reports of an aircraft in trouble, the senior controller could do nothing more for the time being. Canberra ATC was informed that communication with the Viscount had been lost, and Canberra tower stood by to await its arrival. But by VH-TVC's ETA of 8.05pm, there was no sign of the Viscount. The distress phase was introduced, but there were still no reports of anything suggestive of an accident. FSA NOV-DEC 2011 60 At 9.36pm, the ASR (air sea rescue) launch radioed it had circled Botany Bay without seeing any wreckage. Considering the population density in the area, there could be only one inference; TVC had somehow come down in the sea. At first light, aircraft began scouring the open sea off the coast, while a helicopter and motor launches, braving the wild weather, searched the waters of Botany Bay. At 6.30pm the helicopter, investigating an oil slick near the northeastern shore of the bay, sighted what looked like a floating cushion. The ASR launch recovered it, and airline staff identified it as upholstery from the Viscount’s cockpit. Grim evidence Meanwhile, ground searchers checking the north-eastern beaches of Botany Bay came upon small items of cabin furnishings washed ashore—and human remains. At about 8.30am, RAN divers boarded the ASR launch to check some smaller oil slicks on the southern side of the bay. Visibility was poor because of the rain, but presently a police launch drew the divers’ attention to an aluminium structure protruding from the water not far away. It was the tip of a wing. Lying in about five metres of water, it bore the registration VH-TVC. Meanwhile, near where the upholstery had come to the surface, police divers recovered a blood-stained seat cushion, cabin fabric, and more human remains. Further upwind, the divers came upon the disintegrated main wreckage scattered over the seabed in eight metres of water. The investigation begins With the remains of all the victims accounted for, the wreckage was taken to the Department of Civil Aviation's (DCA) hangar at Sydney Airport. By Thursday, all the heavier wreckage had been recovered, but it took a further month of careful underwater searching to find the starboard tailplane and elevator. Some 85 per cent of VH-TVC's structure had now been recovered, examination showing that while the starboard outer wing and tailplane components had sustained little impact damage, the remainder of the aircraft had disintegrated. To determine the reason for the break-up, the outer starboard wing spar and the tailplane structure were examined in detail. There was no sign of fatigue or stress corrosion; the wing spar had failed purely as a result of aerodynamic overloading and the resulting forces on the tailplane caused it to fail almost simultaneously. The port tailplane was distorted and bent upwards, the mode of damage showing this occurred as a result of aerodynamic loads far in excess of normal. Other structures and systems showed no evidence of malfunction before the break-up, nor was there any sign of fire. The engines were running when they struck the water, calculations based on propeller blade angles indicating the aircraft’s speed was at least 300kt and possibly as high as 400kt. Analysis of the wreckage trail showed the Viscount was on a northerly heading about 1nm south of the position of the main wreckage, and at between 3500 and 5500ft, when it broke up. Residents around Botany Bay reported hearing unusual noises, and it seemed probable that the noises they described between 7.20 and 7.30pm were either the in-flight break-up or the aircraft hitting the water. What happened? TVC was fully serviceable, and the crew highly experienced. The only explanation appeared to lie with the violent weather. Indeed, the 29,000-ton P&O Orient liner Orcades, Sydney-bound off the coast at the time, had been battered by a sudden fierce storm soon after receiving a radio message to keep a lookout for wreckage. The ship’s master said it was the first time he had experienced ‘that type of weather in these waters’. A depression of 1001mbs was centred just north of Sydney at the time, moving east-southeast. East of it was a warm, moist, unstable airflow, conducive to the build-up of thunderstorms. The cold front to the west extended for 300km. Large thunderstorms had developed throughout the morning and afternoon, the activity increasing as the centre of the depression approached. Between 6 and 8pm, two major thunderstorms, 25km apart, were over the metropolitan area. The more northerly storm crossed the coast northeast of the city, while the other storm did so 10km south of the airport. Although it was not raining heavily at the airport, extremely heavy rain fell a few miles further south. Aircraft approaching Sydney before TVC’s departure reported severe turbulence. Investigators agreed the only tenable explanation was a loss of control resulting from an encounter with ‘unseen turbulence of extreme magnitude’. That a modern, highperformance airliner, in peak operating condition and flown by an experienced crew, could so unexpectedly be overtaken by total disaster in a matter of seconds, simply because it had flown into turbulence in cloud, was profoundly disturbing. Decisive measures were obviously needed to prevent a repetition. The vital ‘missing link’ Airborne weather radar was now available. Qantas Super Constellations were fitted with it, as were the airline’s newly delivered Boeing 707s. An air navigation order was issued requiring all turbine-powered aircraft on the Australian register to carry weather radar by 1 June 1963. Thus the final ‘missing link’ in electronic navigation aids necessary for the safe conduct of all-weather airline operations was put in place. There was a great deal of evidence to support the possibility that a temporary loss of control resulted from a very severe gust, causing a sudden upset in attitude. With the crew unable to correct it before the aircraft lost substantial height, there would have been a rapid gain in airspeed. The problem would have been compounded if a close lightning flash had simultaneously affected the crew’s vision. But was this enough? Could ATC also assist aircraft to avoid severe turbulence? There was an obvious need for more exchange of information between weather bureaus and ATC. The result was the introduction of a cooperative system under which areas of storm development, displayed on highly sensitive weather radars at meteorological bureaus, were passed to ATC centres, to be superimposed on radar displays used by air traffic controllers. This enabled controllers to see where turbulence was likely to be at its worst and direct aircraft accordingly. Two and a half years before in Maryland, USA, a Viscount had broken up in the air in strikingly similar circumstances. The US Civil Aeronautics Bureau concluded that ‘... a loss of control ... in extreme turbulence, resulting in an involuntary In conjunction with weather radar fitted to aircraft, this system would vastly reduce the likelihood of encounters with turbulence of the severity that caused the tragic loss of VH-TVC. Loss of control 61 PIECE OF THE PUZZLE Because heavy rain also fell to the north and east of the airport about the time of the accident, the investigators believed a new storm cell was probably developing directly in the path of TVC as it climbed to set course to the southwest. At the time communication was lost, it would have been about 2nm southeast of the airport at a height of around 6500ft, climbing at 165kt. Between this point and the structural failure three minutes later, something violent happened, causing the Viscount to suddenly lose as much as 3000ft and increase its speed to perhaps 400 kt. TVC, flying on instruments, probably encountered a gust of unusual intensity. steep descent, following which aerodynamic loads from high speed recovery and turbulence exceeded the design strength of the aircraft,’ had occurred. WHEN IT’S TIME TO GO FSA NOV-DEC 2011 62 Cabin crew, like pilots, spend most of their training in preparation for emergencies Riding an escape slide from the main deck of a widebodied aircraft is a serious, frightening experience, even on a training rig. This is the moment that cabin crew train years for: serving food and drinks only supplements their real jobs – safety and rapid evacuation specialists. The cabin crew who welcome passengers aboard, help them stow all their cabin baggage and serve tea or coffee, are the last line of defence in an emergency. Australia’s excellent safety record fortunately means that all the experience gained in airlines’ six-monthly or annual evacuation drills rarely has to be put into practice in this country. There are so few accidents it can be hard to convince travellers that safety matters. In contrast, in the U.S, according to a National Transportation Safety Board report in 2000, emergency aircraft evacuations happen about once every 11 days. In many of these, the main hazard to passengers proved to be using the slide. In 2006, when a new Airbus A380 underwent mandatory evacuation tests, considered successful, thirty-three of the 873 volunteers were hurt. One volunteer suffered a broken leg and 32 received slide burns. Passenger behaviour in an emergency evacuation can dramatically effect their survival chances. Experienced ﬂyers can be blasé about safety brieﬁngs, but not listening means that the correct procedures will not be top of mind if there is an emergency, and so such passengers may behave inappropriately, or ignore the directions of cabin crew. However, they could also be more at ease with ﬂying and therefore calmer in a crisis. Inexperienced ﬂyers may panic or freeze and can be a particular liability if they are in an exit row. Two Boeing 737 accidents in the 1980s illustrate this contrast. Both involved engine ﬁres that spread to the rest of the plane. In the ﬁrst, in Calgary, Canada, in 1984 all the passengers and crew evacuated within ninety seconds and escaped with only ﬁve serious injuries. In the other, in Manchester, England, 55 of the 137 people on board died. Passengers were still trying to get out after three minutes, by which time the concentration of smoke and toxic chemicals in the cabin was at an incapacitating level. A difference between the two ﬂights might have been that the Calgary passengers were mostly business travellers, while in Manchester they were mainly tourists who rarely ﬂew. Australians are taking to the skies in much greater numbers, so the distinction between business travellers and tourists is being replaced by a division into frequent ﬂyers of assorted hues and shines, with varying levels of attention to safety-related issues. The cabin crew manager of a regional airline mentions an interesting spin-off of the mining boom. She has noticed that OH&S training staff are very good at reminding workers to pay attention to safety brieﬁngs, and many mining companies now run their own evacuation drills. About 71 per cent of aviation fatalities occur after the aircraft has crashed or made a forced landing, and about 80 per cent of all aviation accidents happen shortly before, after, or during take-off or landing, with the majority on landing. ‘Ditching can be controlled and deliberate due to aircraft systems failure (e.g. the Hudson River dual engine failure); or unexpected, as in a rejected take-off with the aircraft over-running the runway into water (many airports are built jutting out into a bay or lake because reclaimed land is cheap). ‘The important point with ditching is that once the aircraft comes to rest the cabin crew automatically launch the rafts, without instruction from the ﬂight crew, because communication systems are often disabled by water. ‘Land evacuation is usually initiated by the captain (unless the tech crew are fatally injured) and may be planned in circumstances such as an engine ﬁre and return to land. However, unexpected events such as a rejected take-off ‘On the captain’s initiation of a land evacuation, the ﬂight crew make sure the cabin is not pressurised and shut down all engines, leaving only a single battery circuit to operate emergency exit lights, ﬂoor passenger guidance lights and emergency PA. The cabin crew then assess exits, open doors and initiate evacuation procedures. ‘Before every take-off we have a discussion about potential engine failure and return to land, and mentally rehearse what we would do.’ Assertiveness saves lives The response and behaviour of the cabin crew signiﬁcantly affects how passengers perceive the level of danger and react to it. Using short concise commands, in an assertive tone, with positive exaggerated gestures and physical contact to encourage people to move as quickly as possible will give passengers conﬁdence and result in a better organised and more efﬁcient evacuation. Even if some passengers do not speak English they will understand clear and strong hand signals. Cabin crew also need to be very clear and assertive when brieﬁng exit row passengers, who may be the difference between life and death for fellow travellers as well as themselves. Exit row seats should not just be a reward for frequent travellers. ‘I asked a passenger in an exit row to stop using his phone, switch it off, and listen to the brieﬁng, but he just went on talking’, says cabin crew member Shelley. Confusion at exits and a passenger’s inability to open an exit door, contributed to the loss of life in the Manchester accident mentioned previously. Australia has always been aware of ensuring that the most appropriate, physically 63 WHEN IT'S TIME TO GO Evacuations can follow a ditching or a forced landing, as well as a crash. Stewart, a senior pilot with a major Australian airline, says that: with runway over-run might lead to a partial gear collapse that renders some exit doors unusable because the aircraft comes to rest at an odd angle. capable people are seated in exit rows. In recent years, many airlines have screened passengers to ensure that exit row seats are allocated to able-bodied adults who are ﬂuent in the carrier’s native language, but, as Shelley says: ‘I actually had an entire family, with two children under seven, as the last to board. Their seats were all in an exit row. Not only that, but they couldn't speak English. ‘It used to be that people could only be in exit rows if they fronted up to a check-in desk, but now they can self-check at a kiosk. If we don't catch it at the boarding readers, the onboard manager should catch it at the door; and the last line of defence is at the brieﬁng, where we are making sure people have read the card, are listening, can understand – and are likely to be able to cope in an emergency. FSA NOV-DEC 2011 64 ‘The other day, I briefed an exit row, and when I explained that the exit weighs 27kg, and please let me know if you might have any difﬁculties with throwing that weight, one lady said “that sounds heavy”. I said, “Yes, it's about the weight of a large suitcase”. She didn't really want to change seats, and then said, “Oh I'll be ﬁne, it probably won't happen anyway”. But because she had mentioned it might be an issue, I was obliged to move her. 7ZRUHFHQWKLJKSURÀOH aviation accidents have also been triumphs of successful evacuation decision-making. QF32: successful controlled disembarkation using stairs Check captain Dave Evans said the most serious part of the engine explosion on QF32 in Singapore came after the landing, when the pilots had to decide whether to evacuate. Fuel was leaking from the left wing and the maximum braking used during the landing made brake temperatures soar to 900°C. The aircraft was on battery power and the crew had use of only one VHF radio dedicated to the ﬁre commander, who was reluctant to send his crew near the plane with an engine still running and fuel pouring onto the hot brakes. ‘We had 433 passengers onboard: we had elderly people, we had wheelchair passengers, so the moment you start evacuating, you are going to have injuries. Deploying a slide before an evacuation had been deemed necessary, and is also unwise,’ Evans told the Royal Aeronautical Society. ‘Should the outside conditions become dangerous you have no way to reverse that, and you are leaving an entry point for smoke/ﬁre into the cabin. There is no point in throwing elderly and/or disabled people down slides, where injuries are a given, unless things deteriorate to a point where life is in danger. At that time, deploy the slides and evacuate by any and all necessary means. Then, and only then, are broken limbs and cracked heads worth the risk. ‘We had fuel, hot brakes and an engine that couldn’t be shut down, so really the safest place was on board the aircraft until things changed. ‘The cabin crew was in alert phase the whole time, ready to evacuate, open doors, inﬂate slides at any moment. The danger gradually abated and, thankfully, we were lucky enough to get everybody off very calmly and methodically down one set of stairs. ‘The cabin crew kept anxious and increasingly hot passengers calm and under control, not only in the air, but also on the ground, while they waited for the stairs to arrive. This accident shows the value of training, experience and the most professional type of CRM (crew resource management).’ US1549: ‘The most successful ditching in aviation history’ US Airways Flight 1549 successfully ditched in the Hudson River near midtown Manhattan six minutes after take-off from LaGuardia Airport, after being disabled by striking a ﬂock of Canada geese. All 155 occupants safely evacuated the aircraft, which was still virtually intact though partially submerged and slowly sinking, and were quickly rescued by nearby watercraft. About 90 seconds before touchdown, the captain announced, ‘Brace for impact’, and the ﬂight attendants instructed the passengers how to do so. Immediately after the A320 had been ditched in mid-river, the pilot gave the ‘evacuate’ order over the PA, and the aircrew began evacuating the 150 passengers, both onto the wings through the four mid-cabin emergency window exits, and into an inﬂatable slide that doubled as a life raft. This was deployed from the front right passenger door (the front left slide failed to operate as intended), while the partially submerged and slowly sinking airliner drifted down the river with the current. Two ﬂight attendants were in the front and one in the rear. Each ﬂight attendant in the front opened a door, which was armed to activate a slide/raft. The port side raft did not immediately deploy so a manual inﬂation handle was pulled. One rear door was opened by a panicking passenger, causing the A320 to ﬁll more quickly with water. Silent review The common mnemonic for this routine is OLDABC: Five people suffered serious injuries, and 73 others minor injuries and hypothermia. Things you hope passengers will remember: Sit up, look up and pay attention to the safety brieﬁng Read and inwardly digest the safety brieﬁng card Keep their seat belts fastened while seated Listen to exit row brieﬁngs and understand how to open emergency doors without blocking the exit 65 Understand the correct brace position WHEN IT'S TIME TO GO Don’t be fooled by the unresponsive gazes. When cabin crew are strapped into their folding seats for take-off and landing they are thinking of more than what will be on the menu in that night’s hotel layover. For every take-off and landing every cabin crewmember performs a silent mental review. They go over where they are positioned in the aircraft, the operation of exits, emergency equipment they might need to use and those passengers who will need additional help to evacuate, where able-boded passengers (who could be useful in an emergency) are sitting, the appropriate crew brace position and the signal to commence brace commands, and the commands they would use to evacuate passengers. The ﬂight attendant in the rear who attempted to reseal the rear door was unable to do so because the impact with the water had ripped a hole in the underside of the aircraft and twisted the fuselage, causing cargo doors to pop open and ﬁlling the plane with water from the rear. The ﬂight attendants urged passengers to move forward by climbing over seats to escape the rising water within the cabin. Have two evacuation plans – one for the closest exit and an alternative if that one is unavailable Count and memorise the number of rows to both exits Abandon their cabin baggage in an emergency Have their money and passport on their person (see point above) Check for ﬁre before opening emergency exits Operation of exits Dispose of the exit correctly Location of emergency equipment Wear sensible shoes – open sandals, high heels and thongs are a hazard in hostile conditions Drills Able-bodied passengers and people with a disability Brace position and signal Commands – and conditions outside the aircraft Silent review is an effective way of removing the distractions that can block situational awareness and hinder quick responses. As CASA cabin safety inspector Susan Rice says, ‘It could be the difference between making the right decision or the wrong decision’. Further reading A Database to Record Human Experience of Evacuation in Aviation Accidents www.caa.co.uk/docs/33/2006_01.pdf Evacuation Commands for Optimal Passenger Management www.atsb.gov.au/publications/2006/grant_20040239.aspx Buy duty-free alcohol on arrival at their destination. Alcohol is ﬂammable and bottles can become lethal missiles Wear clothing made from natural rather than artiﬁcial ﬁbres to protect them from ﬂash burns Help others to evacuate and once clear of the plane move quickly to a safe distance upwind. Public Attitudes, Perceptions and Behaviours towards Cabin Safety Communications www.atsb.gov.au/publications/2006/b20040238.aspx CASA Civil Aviation Order 20.11 (as amended) www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD ::pc=PC_91469 1. (b) right engine will be most critical because the effective thrust line of the left engine is further inboard due to P factor. When a TAF states: ‘BECMG 0101/0103 BKN ST 1200’ it means that (a) at some time between 0100 and 0300 UTC on the 1st, the forecast cloud will become broken stratus at 1200ft above the aerodrome level and this will continue until the end of the forecast period or until the next change in conditions. (d) left engine will be most critical because the effective thrust line of the right engine is further inboard due to P factor. (b) at some time between 0100 and 0300 UTC on the 1st, the forecast cloud will become broken stratus at 1200ft AMSL and this will continue until the end of the forecast period or until the next change in conditions. 66 FSA NOV-DEC 2011 (c) left engine will be most critical because the effective thrust line of the right engine is further outboard due to P factor. (c) from 0100 to 0300 UTC on the 1st, the forecast cloud will be broken stratus at 1200ft above the aerodrome level. 5. (a) increases with increasing height. (d) from 0100 to 0300 UTC on the 1st, the forecast cloud will be broken stratus at 1200ft AMSL. 2. On some light aircraft piston engines there is a red-lined minimum oil temperature for run-up. This requirement may imposed because: (b) decreases with increasing height. (c) remains the same with increasing height. (d) increases with height and temperature. 6. (a) if the oil cooler is on the delivery side of the oil pump, attempting to draw cold viscous oil through the cooler may result in pump cavitation and inadequate lubrication. Compared to a registered aerodrome, a certiﬁed aerodrome: (a) will not have a runway with a non-precision approach. (b) may have at least one runway with a non-precision approach, whereas a registered aerodrome will not have such a runway. (b) if the oil cooler is on the suction side of the oil pump, attempting to draw cold viscous oil through the cooler may result in pump cavitation and inadequate lubrication. (c) may accommodate operations with aircraft of a larger seating or carrying capacity. (c) if the oil cooler is on the delivery side of the oil pump, attempting to force cold viscous oil through the cooler may over-pressure the pump. (d) if the oil cooler is on the suction side of the oil pump, attempting to draw cold viscous oil through the cooler may over-pressure the pump. In a typical normally aspirated piston engine, for the same percentage of rated power, the fuel ﬂow: (d) is not suitable for operations with aircraft with a larger seating or carrying capacity. 7. On a turbocharged piston engine the manifold pressure is increased by: (a) closing the waste gate, which increases the turbine RPM. 3. With increasing altitude, the minimum single-engine control speed (VMCA) on a normally aspirated piston twin-engined aircraft will: (b) closing the waste gate, which decreases the turbine RPM. (c) opening the waste gate, which increases the turbine RPM. (d) opening the waste gate, which decreases the turbine RPM. (a) reduce and may become less than the stall speed. (b) reduce but, because the stall speed also reduces with height, the margin between the two will remain the same. (c) increase and will occur at a lower margin above the stall speed. (d) increase and will occur at a higher margin above the stall speed. 4. On a typical piston twin-engined aircraft where both engines rotate clockwise as viewed from the cockpit, failure of the: (a) right engine will be most critical because the effective thrust line of the left engine is further outboard due to P factor. 8. One difference between class D and class E airspace is that in class D (a) all ﬂights are provided with an air trafﬁc control service, whereas in class E only IFR aircraft are provided with this service. (b) all ﬂights are provided with an air trafﬁc control service, whereas in class E only VFR aircraft are provided with this service. (c) both VFR and IFR ﬂights are permitted, whereas only IFR ﬂights are permitted in class E. (d) all aircraft must be transponder-equipped whereas only IFR aircraft require a transponder in class E. 9. If two-way radio communications are lost the transponder code of: 10. The aeronautical information service (AIS) and MET currently available from the Airservices website under ‘Pilot Brieﬁng’: (a) 7500 should be set and the controller may establish whether the aircraft is receiving transmissions by requesting a selection of code 1200. (a) will remain in service in parallel with NAIPS for the foreseeable future. (b) will remain in service in parallel with NAIPS for the foreseeable future, but the software version of NAIPS is no longer supported. (b) 7500 should be set and the controller may establish whether the aircraft is receiving transmissions by requesting operation of the SPI function (squawk ident). (c) will be decommissioned in 2014, and the service will only be available via NAIPS. (c) 7600 should be set and the controller may establish whether the aircraft is receiving transmissions by requesting operation of the SPI function (squawk ident). (d) will be decommissioned in April 2012, and the service will then only be available via NAIPS. (d) 7600 should be set and the controller may establish whether the aircraft is receiving transmissions by requesting a selection of code 1200. 1. One safety-related characteristic of lithium-ion batteries is that, if exposed to high temperatures: 6. (a) a different diameter cylinder bore on each side. (a) thermal runaway may occur due to increased internal dissipation and the battery may burst or catch ﬁre. (b) a different diameter piston on either side. (c) a piston rod on one side of the piston only and, as a result, the force available to extend the rod is reduced. (b) thermal runaway may occur due to reduced internal dissipation and the battery may burst or catch ﬁre. (d) a piston rod on one side of the piston only and, as a result, the force available to retract the rod is reduced. (c) the terminal voltage may rise to the point at which damage may occur to the connected equipment. (d) the output current may increase to the point at which damage may occur to connected equipment. 2. 7. (c) are not damaged by overcharging. (c) reduce the bending moment of the wing both when taxiing and in ﬂight. Antihistamines are a category of drug that may have a negative impact on a person’s ability to work safely in an aviation environment and: (d) increase the bending moment of the wing both when taxiing and in ﬂight. 8. (b) may be found in non-prescription medications but are testable under a CASA DAMP. (a) compression during taxiing and tension during ﬂight. (c) are only found in prescription medications. (b) tension during taxiing and compression during ﬂight. (d) have effects that are not modiﬁed by alcohol. (b) two-lug anchor nut. (c) corner anchor nut. (d) one-lug anchor nut. 5. (c) tension during all operations. MS 21080 is the part number of a: (a) thin self-locking nut. An aircraft tubing identiﬁer with a green band and identical rectangles indicates: (a) instrument air. (b) ﬁre protection. (c) breathing oxygen. (d) water injection. On aircraft where the undercarriage is attached to the wing rather than the fuselage, the top spar cap outboard of the undercarriage attachment is in: (d) compression during all operations. 9. The permissible altimeter error at 2000ft under FAR 43 and as proposed for adoption in Australia via changes to CAO 100.5 is: (a) ±3%. (b) ±20ft. (c) ±30ft. (d) ±100ft. 10. A constant displacement pump: (a) will absorb a constant driving power regardless of output pressure. (b) delivers a constant pressure regardless of demand. (c) delivers a volume of ﬂuid per revolution as determined by demand. (d) delivers a ﬁxed volume of ﬂuid per revolution of the pump. QUIZ (d) do not self-discharge in storage. 4. Compared to fuel in the inboard main tanks, the structural effect of relocating the same mass of fuel to the tip tanks is: (b) to increase the wings’ downward bending moment when taxiing but to reduce the upward bending moment during ﬂight. (b) can be permanently damaged by over discharging. (a) may be found in non-prescription medications but are not testable under a CASA DAMP. 67 (a) to decrease the wings’ downward bending moment when taxiing but increase the upward bending moment during normal ﬂight. Lithium-ion battery packs (a) should be completely discharged when shipping or storing. 3. Unbalanced double-acting hydraulic linear actuators have: GNSS RNAV Approach 3. You are in inbound to Yarram (YYRM) Victoria, tracking from Wonthaggi (WON) VOR and NDB (Refer ERC 2), in a Beechcraft B55 Baron (Category B). (a) You may only use the GNSS RNAV alternate minima for planning purposes if it is TSO 145/146 or equivalentapproved. You are GNSSRNAV endorsed and current. The aircraft is equipped with ILS, VOR, ADF and approach-approved GPS (current database). The following questions relate to this ﬂight for the RNAV Rwy 09 (plate dated 12 Mar 2009). 1. (b) You may use the alternate minima for all GNSS RNAV equipment that is approach-approved. (c) GNSS RNAV cannot yet be used for alternate planning purposes, so YYRM must be treated as ‘No Aid’ alternate criteria i.e. no more than ‘SCT’ cloud below LSALT + 500ft and visibility not less than 8km. At the ﬂight planning stage, you have calculated the LSALT from WON to YYRM, since it is a non-published track. Which of the following represents the GNSS method for this LSALT? (d) GNSS RNAV cannot yet be used for alternate planning purposes, so YYRN must be treated as ‘No Aid’ alternate criteria i.e. no more than ‘SCT’ cloud below LSALT and visibility not less than 5km. (a) (b) 68 Approaching 30 GPS to run YYRM on track from WON at 5000ft in cloud you plan top of descent. You have previously loaded the Rwy 09 RNAV approach. RAIM is available. 4. FSA NOV-DEC 2011 Also at the planning stage you consider the alternate requirement for the ‘No Aid’ aerodrome at YYRM. Which of the following is correct? Which of the following is correct concerning the scaling as you cross 30 miles to run? (a) The GNSS unit is in ‘Enroute’ mode with a scale of 1nm per dot until 25miles when it will go to ‘Terminal’ mode with a scale of 0.2nm ‘per dot’. (c) (b) The GNSS unit will change from ‘Enroute’ to ‘Terminal’ mode as you pass 30 miles to run. The scaling therefore changes from 1 mile to 0.2 mile ‘per dot’. (c) The GNSS unit will always be in ‘Approach Active’ mode with a scale of 0.06nm per dot with an approach loaded into the ﬂight plan. (d) (d) The GNSS unit will change from ‘Enroute’ to ‘Approach Active’ mode as you pass 30 miles. The scaling therefore changes from 1 mile to 0.06 mile ‘per dot’. 2. As a back-up LSALT calculation in case a RAIM loss was to occur, which of the following is the method using VOR/NDB? (a) Having passed 25 miles to run you activate the approach to track direct to YRMWB. 5. What is the lowest altitude to which you may descent enroute to YRMWB? (a) The grid LSALT of 3900ft. (b) The calculated LSALT between Wonthaggi and Yarram. (c) The M.S.A. YYRM of 3900ft. (b) (d) The M.S.A. YYRM of 2600ft. Approaching YRMWB on a heading of 105M, you consider the sector entry and holding pattern if it is required. (c) 6. What are the sector entry and holding details? (a) Sector 1 (parallel) entry, left hand, 1 minute. (b) Sector 2 (teardrop) entry, left hand, 1 minute. (c) Sector 3 (straight in) entry, left hand, 1 minute. (d) (d) No holding details at YRMWB, therefore you must go straight into the approach. 7. If a hold was necessary at YRMWB, you would need to suspend the GPS, otherwise the GPS will sequence to the next waypoint. True or false? (a) True. (b) False. Now crossing YRMWF, the GPS sequences to YRMWM and you continue descent to M.D.A. You observe the groundspeed is higher than expected and thus determine there is a westerly component wind of 15kt. 10. What is your M.D.A going to be and how will you join the circuit when visual? You now have the GPS sequencing, crossing YRMWB at 3900ft and establishing on a track of 087º. (a) 660ft, straight in runway 09. 8. (c) 710ft, break left to join a right downwind for runway 27. What distance readout will you see and to what height may you now descend? (b) 710ft, break right to join a left downwind for runway 27. (d) 660ft, break right to join a left downwind for runway 27. (a) 15 miles to YRMWM and 3500ft. (b) 12.5 miles to YRMWM and 2700ft. (c) 5 miles to YRMWI and 2700ft. (d) 5 miles to YRMWI and 3500ft. Now crossing YRMWI, you may descend to not below 2100ft. 9. What distance readout will you see to enable the descent to 1600ft or to cross check the 3º proﬁle height of 2430ft? 69 (a) 7 miles to YRMWM. (b) 5 miles to YRMWF. (c) 3 miles from YRMWI. (d) 2 miles to YRMWF. QUIZ Master of Aviation Management B6285 Our Master of Aviation Management graduates have the knowledge, skill and vision to master the challenges of changing management practice in the aviation industry. By choosing this degree, you will have the opportunity to develop critical thinking and analytical skills, which are relevant across aviation and the general transportation industry. We allow you to create a personalised program oﬀered 100% online! “I never thought I was conscientious enough to study without the classroom environment but the structure of online courses at the University of Newcastle made it extremely easy.” Nicola – Master of Aviation Management So if you’re looking for that career edge but want to maintain the balance in your life – the choice is simple! To ﬁnd out more: www.GradSchool.com.au DESIGNED FOR LIFE CALENDAR 2011–2012 11 NOVEMBER FSA NOV-DEC 2011 70 1-3 1-3 2 2 2-3 3 5 7 8 8 9 9 12 16 16 16 16 - 17 16 - 17 22 23 26 28 29 - 30 30 International Air Safety Seminar 2011 European Cabin Safety Conference AvSafety Seminar AvSafety Seminar Asia Pacific Cabin Safety Working Group Meeting AvSafety Seminar 5th Catalina Festival AvSafety Seminar AvSafety Seminar AvSafety Seminar AvSafety Seminar AvSafety Seminar AvSafety Seminar AvSafety Seminar AvSafety Seminar AvSafety Seminar Certification Flight Testing Seminar Defence Human Sciences Symposium AvSafety Seminar AvSafety Seminar Aircraft Airworthiness Seminar Airborne Early Warning and Control Conference Aerial Emergency Response International Conference and Exhibition Police Aviation Asia Mandarin Orchard, Singapore Frankfurt, Germany Gunnedah, NSW Albany, WA Auckland, New Zealand Narrabri, NSW Lake Macquarie, NSW Wilpena Pound, SA Tamworth, NSW Marree, SA William Creek, SA Armidale, NSW Toogoolawah, Qld Southport, Qld Geraldton, WA Goolwa, SA Woden, ACT Melbourne, Vic Tumut, NSW Cooma, NSW Mildura, Vic Kuala Lumpur, Malaysia www.flightsafety.org www.ldmaxaviation.com www.casa.gov.au www.casa.gov.au www.asasi.org/apcswg/newindex.htm www.casa.gov.au Bill: 0438 448 115 or firstname.lastname@example.org www.casa.gov.au www.casa.gov.au www.casa.gov.au www.casa.gov.au www.casa.gov.au www.casa.gov.au www.casa.gov.au www.casa.gov.au www.casa.gov.au www.casa.gov.au www.dsto.defence.gov.au/dhss2011/ www.casa.gov.au www.casa.gov.au www.casa.gov.au/ageingaircraft www.tangentlink.com Kuala Lumpur, Malaysia www.tangentlink.com Kuala Lumpur, Malaysia www.tangentlink.com Calgary, Canada Calgary, Canada Sydney, NSW Melbourne, Vic www.beyondriskmgmt.com/ www.beyondriskmgmt.com/ www.airservicessustralia.com/ www.airservicessustralia.com/ www.casa.gov.au 12 DECEMBER 2-3 5-6 6 14 23 A practical approach to safety management systems A practical approach to quality assurance and auditing Airservices Australia GA pilots information night Airservices Australia GA pilots information night CASA offices shut down for Christmas/New Year 01 JANUARY 2012 3 25 - 26 CASA offices re-open after Christmas/New Year Aerial Firefighting Conference and Exhibition Sacramento, California, USA KEY www.casa.gov.au www.tangentlink.com CASA events Other organisations' events AUSTRALIAN ON SALE NOW Become an AOPA member and start receiving your free copies of the Australian Pilot magazine among other beneﬁts! Join online today at www.aopa.com.au 71 FLYING OPS MAINTENANCE IFR OPERATIONS 1. a. GEN 3.6.6 2. b. this consideration is uniquely important in operating such engines. 3. a. at some altitudes they may cross over. 4. c. 5. c. can be verified from power setting tables. 6. c. CASR Part 139; Certified aerodromes have the more stringent requirements. 7. a. closing the waste gate diverts more exhaust flow through the turbine. 8. a. ENR 1.4.2. 9. c. ENR 1.6 . 6.4 10. d. the internet briefing service will only be available via NAIPS after April 2012. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. 2. 3. 4. c. d. a. b. 5. 6. 7. 8. c. c. a. d. a. b. a. d. c. d. b. b. c. d. AIP GEN 3.3 -17 Para 4.9 AIP GEN 3.3 -17 Para 4.8 AIP GEN 1.5 -16 Para 126.96.36.199 Relevant GNSS unit handbook. Note the scaling change to approach ‘active’ occurs past the intermediate fix with RAIM available. AIP ENR 1.5 -14 Para 2.2.1 AIP ENR 1.5 -24 Para 3.3.4 Relevant GNSS unit handbook. YYRM Rwy 09 approach plate. Note, because the GNSS unit can only show the distance to the next waypoint and not total distance, it is very important that if there are intermediate descents between the waypoints, such as this one at YRM, you must have prepared what you expect to see as a distance for that intermediate descent. 9. d. 10. b. YYRM Rwy 09 approach plate. Note that the westerly wind means circling for Rwy 27 and there is a no circling restriction to the north of the field. QUIZ ANSWERS QUIZ Phone 02 9791 9099 s Email email@example.com s ANSWERS Web www.aopa.com.au NO ONE IS MORE QUALIFIED TO KEEP YOU QUALIFIED. We have an unrivalled 40-year reputation, having trained 100s of pilots With SA’s widest range of aircraft for training, your employment chances are greatly improved We are SA’s leading Multi-Engine Instrument Rating training provider We have ATOs on staff, authorised for all licences and ratings Training done from our newly refurbished facilities at Adelaide Airport, with the controlled airspace procedures of an international airport slipperyﬁsh_as_1009 Our costs are always keen and competitive Quite simply - there is no ﬂight training service in South Australia better equipped than Air South. 72 Go and shop at the online store CALLSIGN PARAFIELD ETD TAS TYPE SARTIME WIND UTC LOCAL CENSAR 1800 814 931 Standing personal minimums checklist TAFS ARFORS (Review every 100 hours, or annually, or on completion of new rating/endorsement) Endorsement, training & experience summary JANDAKOT S VISUAL PILOT GUIDE 2010 ELEV 55 RN APRON ELEV 31 NORTHE CAMDEN Compass Swing Bay C1 RO N ELEV 35 RA L AP BANKSTOWN D1 NT Key Run-up bay TWR Intermediate holding position Runway holding position Runway incursion hotspot F1 Apron grass area E1 ELEV 94 C2 C3 ELEV 35 E2 E3 ELEV 39 Taxiway crossing (pedestrian) N ROUnsealed Taxiway F2 RN HE UT SO AP TWR G1 F3 G3 Manoeuvring area Aircraft parking ELEV 94 Terminal TWR An area on the aerodrome intended to accommodate aircraft for the purpose of loading or unloading passengers, cargo, fuelling, parking, or maintenance. That part of the aerodrome to be used for take-off, landing and taxiing Helicopter of aircraft, excluding aprons. Training That part of the aerodrome to be used for take-off, landing and taxiing of aircraft,Area consisting of the manoeuvring area and the aprons. VISUAL PILOT GUIDE 2010 Aircraft Key ELEV 95 parking Aircraft Run-up bay parking NDB Operation on the aerodrome Intermediate holding position 281 Apron area – no taxi clearance required. Monitor Ground on 119.9 MHz. Runway holding position Taxiway – taxi clearance from Ground required before entering this area. Runway incursion hotspot Toll facility Runway – specific clearance required from ATC before94entering this area. ELEV Key Definitions Revised self-assessment Maximum crosswind as % of pilot’s operating handbook figure for type Minimum runway requirement as % of pilot’s operating handbook figure for type Minimum visibility – day VFR Minimum visibility – night VFR Minimum ceiling – day VFR Minimum ceiling – night VFR Surface wind speed & gusts Maximum cross wind Other VFR (eg: mountain flying, over water beyond gliding distance) Fuel reserves (day VFR) Fuel reserves (night VFR) NOTAM POSN NAV/COMM LOG TR (m) HDG (m) G/S DIST ETI EST Left tank Minutes Gauge each tank Example: 100 hour VFR pilot 50% 150% 12km 15km 3,000 feet 5,000 feet 15 knots 5 knot gust 7 knots Consult instructor/ mentor 1 hour 1½ hours Your personal minimums Right tank Time LOCATION FIR HEAD OFFICE ALT Time Minutes each tank Gauge 180 180 150 150 120 120 90 90 60 60 ATA ATD FUEL (mins) NAV/COM FREQ FLIGHT TAXI *FIXED RES (45) *VRB RES ALTN HOLDING INTER (30) TEMPO (60) TOTAL FUEL * Recommended VFR LEVELS 30 30 PILOT NOTES ________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ 359 EVENS + 500 180 www.casa.gov.au | p.131 757 Run-up bay 1108.1571 P Apron area An area on the aerodrome intended to accommodate aircraft for the purpose Intermediateof holding positionpassengers, cargo, fuelling, parking, or maintenance. loading or unloading Runway position Manoeuvring area holding That part of the aerodrome to be used for take-off, landing and taxiing of aircraft, excluding aprons. Movement area Definitions Apron area Manoeuvring area 1108.1571 J Movement area Key Run-up bay Intermediate holding position Runway holding position Runway incursion hotspot Operation on the aerodrome Definitions Apron area Manoeuvring area 1108.1571 C Movement area That part of the aerodrome to be used for take-off, landing and taxiing of aircraft, consisting of the manoeuvring area and the aprons. An area on the aerodrome intended to accommodate aircraft for the purpose Operation on thepassengers, aerodromecargo, fuelling, parking, or maintenance. of loading or unloading Apron area – no taxi clearance required. Monitor Ground on 124.3 MHz. That part of the aerodrome for take-off, landing andbefore taxiing Taxiwayto– be taxiused clearance from Ground required entering this area. of aircraft, excluding Runway aprons. – specific clearance required from ATC before entering this area. That part of the aerodrome to be used for take-off, landing and taxiing of aircraft, consisting of the manoeuvring area and the aprons. Apron area – no taxi clearance required. Monitor Ground on 121.9 MHz. Taxiway – taxi clearance from Ground required before entering this area. Runway – specific clearance required from ATC before entering this area. An area on the aerodrome intended to accommodate aircraft for the purpose of loading or unloading passengers, cargo, fuelling, parking, or maintenance. VISUAL V SU PILOT O GUIDE GU 2010 0 That part of the aerodrome to be used for take-off, landing and taxiing of aircraft, excluding aprons. That part of the aerodrome to be used for take-off, landing and taxiing of aircraft, consisting of the manoeuvring area and the aprons. Operation on the aerodrome Apron area – no taxi clearance required. Monitor Ground on 119.9 MHz. Taxiway – taxi clearance from Ground required before entering this area. Runway – specific clearance required from ATC before entering this area. * please note that a postage and handling fee of $15 applies to each order 1108.1571 B flightsafety … essential aviation reading INSIDE JAN - FEB 2012 What do you know? Safety management systems The light fantastic: the promise and hazards of composite materials All present and correct: checklist use and design And … more close calls 000 ODDS + 500 179 1009.1351 (d) Movement area Aircraft parking VISUAL PILOT GUIDE 2010 Definitions Apron area G2 MELBOURNE BASIN 1108.1571 (c) v2 For these and many more other free* safety promotion products visit the CASA online store at www.casa.gov.au/onlinestore Self-assessment factors Endorsement/ratings (eg: night VFR, MPPC) Flight review Time since last instruction in aircraft #1: Time since last instruction in aircraft #2: Time since last instruction in aircraft #3: Familiarity with avionics/GPS Experience Total flying time in hours Number of years flying Hours in the last year Hours in this or identical aircraft in last year Landings in last year Night hours in last year Night landings in last year High density altitude hours in last year Mountainous terrain hours in last year Strong crosswind or gusty landings in last year Personal minimums SYDNEY BASIN TWR CE FSA NOV-DEC 2011 For more information and a full price list, contact Air South on (08) 8234 3244 or visit www.airsouth.com.au | Archerfield | Bankstown | Cairns | Cambridge | Camden | Jandakot | Launceston | Moorabbin | Parafield | Online in flight flig gh planning ning for Australian aviation Your interactive guide to operations Y in and around controlled airspace www.casa.gov.au/ontrack ;OLYLOHZUL]LYILLUHIL[[LY[PTL [VIL^P[ONVVKWLVWSL Good people to be with. 8),0UZ\YHUJL(\Z[YHSPH3PTP[LK()5! 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